NCM 107: Maternal and Child Nursing Module 3 PDF

NCM 107: MATERNAL AND CHILD NURSING NCM 107 – MODULE 3 PROGESTERONE DEPRIVATION THEORY Unit 1. Theories of Labor o Progesterone produced by the placenta i. Uterine Stretch Theory relaxes uterine smoot...

NCM 107: MATERNAL AND CHILD NURSING NCM 107 – MODULE 3 PROGESTERONE DEPRIVATION THEORY Unit 1. Theories of Labor o Progesterone produced by the placenta i. Uterine Stretch Theory relaxes uterine smooth muscle by ii. Fetal Oxytocin Theory interfering with conduction of the impulses iii. Progesterone Deprivation Theory form one cell to the next. Changes in the iv. Placental Aging Theory ratio of estrogen to progesterone occur, v. Fetal Cortisol Secretion Theory increasing estrogen in relation to vi. Rising Prostaglandin Theory progesterone, which is interpreted as progesterone withdrawal. Decreased UNIT 1. Theories of Labor Onset amount of progesterone inhibits the relaxation effect on the uterus initiating THE UTERINE STRETCH THEORY labor onset. o As the fetus inside the mother's womb Prepares the uterus for labor increases its size, the uterine muscle Withdrawal of progesterone, causes stretches resulting to prostaglandins the onset of labor release. Prostaglandins are compounds in the body made of fats that have hormone- PLACENTAL AGING THEORY like effects. Some known effects include o The aging placenta cannot supply enough uterine cramping and increase sensitivity to nutrients to the growing fetus because it pain. reaches a set age which triggers uterine o Unlike other hormones, prostaglandins contraction aren't released from a specific gland; instead the body has a number of tissues FETAL CORTISOL SECRETION THEORY that produces prostaglandins. o Rising fetal cortisol levels reduce o A woman starts to have a larger amount of progesterone formation and increase certain types of prostaglandins in her prostaglandin formation which stimulates uterine tissue during late pregnancy uterine contraction. (Healthline2020) specifically at the onset of Prostaglandins contacts the uterus labor. RISING PROSTAGLANDIN THEORY FETAL OXYTOCIN THEORY o The fetal membrane (amnion and decidua) o Oxytocin is a patent uterotoxin (uterine begins to produce prostaglandins, which muscle contractant) Secretion of oxytocin stimulate contractions (Bienstock, Fox, & increases just before 37-42 weeks of Wallach, 2015). gestation. Oxytocin stimulates contractions thus facilitating sealing of ruptured THE FIVE P’s capillaries which then stops bleeding. The passageway (pelvis) o Due to its contractile activity on the The passenger (The fetus) myometrium labor is initiated. Then the The power (The ability of the uterus to contract) fetus head presses on the cervix, which The position (position of the baby in the uterus) stimulates the release of oxytocin from the The psychological response of the mother posterior pituitary. Oxytocin stimulation works together with prostaglandins to initiate contractions. PARTS OF PELVIS o The oxytocin acts as a contractant to help in o False Pelvis – area within entire pelvic girdle pushing out the baby in labor o True Pelvis – are below pelvic brim o The uterus is necessary to contract to seal of the blood vessels to stop the bleeding of THE PASSAGEWAY the pregnant patient which is caused by o Station Zero – means that the baby is oxytocin engaged o Major function after delivery: Make sure that o The passageway refers to the route a fetus the uterus is “rock hard” to stop the must travel from the uterus through the bleeding. cervix and vagina to the external perineum. In most cases, disproportion occurs between the fetus and pelvis due to the faulty structure of the pelvis. If the DIAMANTE, P.M. BSN 2F  NCM 107: MATERNAL AND CHILD NURSING disproportion is caused by the fetus, the Importance of sutures and fontaneis: fetal head is presenting to the birth canal at 1. Skull's Flexibility less than its narrowest diameter, therefore 2. Moulding of the fetal head in cephalic Normal Spontaneous Vaginal delivery is not positions feasible. The passage (a woman's pelvis) 3. Diameter of the fetal skull should be of adequate size and contour to accommodate the passenger (fetus) to Moulding - is the overlapping of skull bones along travel out of the vaginal canal. the suture lines, which causes a change in the o The Normal Pelvis- The ideal normal shape of the fetal skull to one long and narrow, a female is the gynecoid pelvis: shape that facilitates passage through the rigid ▪ BRIM - slightly oval transversely. pelvis. It is caused by the force of uterine ▪ SACRAL PROMONTORY - not contractions as the vertex of the head is pressed prominent. against the not yet dilated cervix ▪ TRANSVERSE DIAMETER - slightly longer than the anteroposterior. PASSENGER: FETOPELVIC RELATIONSHIPS ▪ SIDEWALLS - parallel and straight. 1. Fetal Attitude is the degree of flexion a fetus ▪ SCHIAL SPINES - not prominent. assumes during labor or the relation of the fetal parts to each other. Factors considered for the passage of the fetus to ▪ Normal attitude - flexion of neck, the pelvis: arms and legs Obstetric conjugate of the inlet ▪ Abnormal attitude - hyperextension Distance between ischial spines Fetal attitude changes cause larger Subpubic angle & transverse diameters diameter of fetal head to present to pelvis. Posterior & sagittal diameters of the 3 planes 2. Fetal Lie is the relationship between the long axis of the fetal body and the long axis of a Curve & length of the sacrum woman's body-regardless whether the fetus Three Anteroposterior Diameters of the Pelvic Inlet: is lying in a horizontal (transverse) or a vertical (longitudinal) position 12.5 cm by (Pelvimetry) Obstetric Conjugate – conjugata vera (11 3. Fetal presentation indicates the body part cm) upper margin subtract 1.5-2 from as the first to contact the cervix or be diagonal conjugate. delivered first and is determined by the True Conjugate – conjugata vera (11.5cm) combination of fetal lie and the degree of upper margin-sacral promontry. fetal flexion (attitude). THE PASSENGER (FETUS) o The head is the body part of the fetus that has the widest diameter that passes through the pelvic ring depending on the structure (bones, fontanelles, and suture lines) and alignment with the pelvis. Fetal head's diameter is the ability of fetus to fit thru the maternal pelvis. Factors which determine the way it moves thru the birth canal: 1. Fetal Head's Size ▪ Fetal head/skull: ✓ Sutures ✓ Fontanels 2. Fetopelvic Relationships. ▪ Fetal attitude Type of Fetal Presentations and Classification of ▪ Fetal Lie - vertical Fetal presentation 3. Fetal presentation a. Cephalic presentation - vertex, military, 4. Fetal position brow or face DIAMANTE, P.M. BSN 2F  NCM 107: MATERNAL AND CHILD NURSING b. Breech presentations - complete, frank or footling o FALSE LABOR CONTRACTIONS c. Shoulder presentation - occurs rarely; ▪ Are irregular and don’t have a shoulder, arm, back, abdomen or side pattern ▪ Are usually mild and don’t get FETAL STATION stronger over time ▪ Can be strong, then weak ▪ May stop when you walk, rest, or change position. Pain is usually only in the front. PRELIMINARY SIGNS OF LABOR 1. BRAXTON HICKS CONTRACTIONS ▪ Last week or days before labor a woman usually notices strong Braxton Hicks contractions ▪ A woman having her first child may have such difficulty distinguishing between these and true POWERS (UTERINE CONTRACTIONS) contractions. o Initiated by pacemakers - uterotubal 2. RIPENING OF THE CERVIX junction, contraction waves meet at the ▪ An internal sign seen only on pelvic fundus, contraction waves progress examination. downward ▪ Throughout pregnancy, the cervix o Shortening of muscle fibers feels softer than normal, like the o Retractions Intrauterine pressure consistency of an earlobe (Goodell’s o Additional force “maternal pushing” sign) Increase Intra Abdominal pressure ▪ At term, the cervix becomes softer (expulsion of the fetus) and can be described as “butter soft” and it tips forward PSYCHE 3. LIGHTENING o Concerns of a woman during labor and birth 4. INCREASED IN LEVEL OF ACTIVITY o Preparation for childbirth 5. SLIGHT LOSS WEIGHT o Socio-cultural heritage 6. BACKACHE o Previous childbirth experience o Support from significant others STAGES OF LABOR AND DELIVERY o Emotional status 1. The First Stage Of Labor o Environmental influence a) The latent phase or early phase) ▪ Begins at the onset of regularly COMMON SIGNS OF LABOR perceived uterine contractions and o TRUE LABOR CONTRACTIONS ends when rapid cervical dilatation ▪ Come regularly and get closer begins. together over time ▪ Last approximately 6 hours in a ▪ Steadily get stronger nullipara and 4.5 hours in a ▪ Last 60 to 90 seconds each multipara ▪ Keep coming when you rest or move ▪ Contractions are mild and short (20 around to 40 secs) ▪ Pain starts in back and moves to ▪ Cervical effacement occurs front ▪ Cervical dilation from 0 to 3 cm. ▪ Painful uterine contractions (labour ▪ Minimal discomfort pain) at regular intervals ▪ “Nonripe” cervix will have a longer ▪ Contraction with increasing than usual latent phase. intensity and duration b) The active phase ▪ Progressive effacement and ▪ Cervical dilatation occurs more dilatation of the cervix rapidly (4cm to 7cm) ▪ Formation of the “bag of waters” DIAMANTE, P.M. BSN 2F  NCM 107: MATERNAL AND CHILD NURSING ▪ Contractions stronger (40 to 60 secs) occurring every 3 to 5 mins 3. The Third Stage Of Labor ▪ Last approximately 3 hours in a Placental Stage - begins with the birth of the infant nullipara and 2 hours in a multipara and ends with the delivery of the placenta. “show” increases a. Placental expulsion ▪ Spontaneous rupture of the ▪ Delivered either by the natural membranes may occur bearing-down by the mother or by ▪ True discomfort may felt by a woman the gentle pressure on the c) The transition phase contracted uterine fundus by the ▪ Maximum dilatation (8 cm to 10 cm physician or nurse-midwife (Crede’s ▪ Contractions duration (60 to 90 Maneuver) secs) occurs every 2 to 3 mins ▪ Check bp ▪ At the end of this phase, full b. Placental separation dilatation and complete effacement ▪ Lengthening of the umbilical cord have occurred ▪ Sudden gush of blood ▪ Intense discomfort, anxiety, panic, ▪ Change in the shape of the uterus irritability ▪ Separates first at its center and last at its edges 2. The Second Stage Of Labor ▪ SCHULTZE - the fetal membrane o Period from full dilatation and cervical surface “shiny” effacement to the birth of overwhelming ▪ DUNCAN – the irregular maternal contractions. surface “dirty” o Uncontrollable urge to push or bear down ▪ Normal blood loss is 300 to 500 ml with contractions. ▪ Excites powerful uterine o Fetus descends in the pelvis contraction, aids in early placental o Perineum begins to bulge and appear tense separation, blood loss and duration once fetal head touches the internal side of of the third stage of labor. (5 mins) the perineum. o Stool may be expelled from the pressure. ACTIVE MANAGEMENT OF THE THIRD STAGE OF o Fetal scalp becomes visible at the opening LABOR: to the vagina. 1) Prophylactic uterotonic after delivery of the o “Crowning” occurs. baby. (Oxytocin 10 IU intramuscularly) 2) Cord clamping, cutting and controlled cord Management of the Second Stage of labor: traction of the umbilical cord. i. Fetal heart rate monitoring at least every 5 3) Uterine massage to prevent uterine atony minutes and after each contraction if the and minimizes bleeding. woman is in complete cervical dilation. ii. Empty the bladder to facilitate descent of LABOR the fetal head. o Is the process of delivering a baby and the iii. Avoid lying down in supine position or semi- placenta, membranes, and umbilical cord supine, rather adopt a comfortable position. from the uterus to the vagina to the outside iv. Light diet or if possible keep client on NPO world. Usually, it is divided into four stages. to prevent vomiting. The different stages of labor need to be v. Instruct the woman in labor not to push if monitored and recorded in order to ensure the cervix is not fully dilated (vaginal the safety of the mother and the baby as examination) to prevent damage of the well. perineal tissue. o It could also help determine expected vi. Support the perineum to increase flexion of outcomes and nursing intervention in a the fetal head and relieve pressure on the woman experiencing labor and birth. perineum. (Ritgen Maneuver) vii. Check that the umbilical cord does not coil CAUSES OF ONSET OF LABOUR around the infant’s neck. i. MECHANICAL viii. Deliver the shoulder and body in gentle ▪ Uterine distension theory continuous posterior traction on the head ▪ Stretch of the lower uterine and lateral flexion, to deliver the entire ▪ segment by presenting pact shoulder over the perineum. DIAMANTE, P.M. BSN 2F  NCM 107: MATERNAL AND CHILD NURSING ▪ Mechanical stretching of cervix 2. Ensure the fundus remains firm. Massage the (Ferguson’s reflex) and stripping of fundus every 15 minutes during the first hour, every fetal membranes 30 minutes during the next hour, and then, every ii. BIOCHEMICAL hour until the patient is ready for transfer. ▪ Oxytocin NOTE: A boggy uterus many indicate uterine ▪ Prostaglandins atony or retained placental fragments. ▪ PAF Boggy refers to being inadequately ▪ Angiotensin II contracted and having a spongy rather than ▪ Histamine firm feeling. ▪ Serotonin and others 3. Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the uterus CARDINAL MOVEMENTS OF LABOR ▪ Identify lochia amounts as small, moderate, or heavy (large) 4. Observe the patient's urinary bladder for distention. ▪ Characteristics of a full bladder: Bulging of the lower abdomen Spongy feeling mass between the fundus and the pubis. Displaced uterus from the midline, usually to the right. Increased lochia flow. 4. The Fourth Stage Of Labor o The hour or two after delivery when the tone of the uterus is reestablished as the uterus contracts again, expelling any remaining contents (placenta and placental fragments.) These contractions are hastened by breastfeeding, which stimulates production of the hormone oxytocin. The mother may experience: 1. Tremors and chills 2. After-pains 3. Episiotomy or tears 4. Hemorrhoids 5. Postural hypotension (dizziness, fainting) NURSING MANAGEMENT DURING THE FOURTH STAGE OF LABOR: 1. Monitor vital signs and the general condition of the mother. ▪ Take BP, PR, and RR every 15 minutes for an hour, then every 30 minutes for an hour, and then every hour as long as the patient is stable. Take the patient’s temperature every hour. ▪ Keep the client warm with blanket if ever chills is experienced. ▪ Observe for uterine atony or hemorrhage. ▪ Encourage the patient to drink fluids. DIAMANTE, P.M. BSN 2F