Labor and Birth PDF

LABOR AND BIRTH C NURS 102: Ricci Maternity and Pediatric Nursing Ch 13 & 14 Factors Influencing the Onset of Labor Uterine stretch Progesterone withdrawal Increased oxytocin sensitivity Increased release of prostaglandins  Premonitory Signs of Labor Cervical changes (cervica...

LABOR AND BIRTH C NURS 102: Ricci Maternity and Pediatric Nursing Ch 13 & 14 Factors Influencing the Onset of Labor Uterine stretch Progesterone withdrawal Increased oxytocin sensitivity Increased release of prostaglandins  Premonitory Signs of Labor Cervical changes (cervical softening, possible cervical dilation) Lightening (baby “drops” in to maternal pelvis) Increased energy level (nesting) Bloody show Loading… Braxton Hicks contractions Spontaneous rupture of membranes True Versus False Labor True labor False Labor Contractions regular, 4-6 min apart, Irregular, not close together last 30-60 sec Do not get stronger over time or Become stronger with time, vaginal alternate strong/weak pressure Felt in front of abdomen Start in back and radiate to abdomen May slow down or stop with Continue through position changes, walking or position change walking Stay at home, drink fluids and walk Go if 5 min apart, last 45-60 sec, around, monitor for changes cannot talk through contraction  Critical Factors Affecting Labor and Birth (“5 P’s”) Passageway (birth canal: pelvis & soft tissues) Passenger (fetus and placenta) Powers (contractions) Loading… Position (maternal) Psychological response  Five Additional Factors Affecting the Labor Process Philosophy (low-tech, high-touch) Partners (support caregivers) Patience (natural timing) Patient preparation (childbirth knowledge base) Pain control (comfort measures) Passageway: Bony Pelvis Linea terminalis: division of false and true pelvis True pelvis (below linea terminalis) Inlet Mid-pelvis Outlet (pelvic measurements) False pelvis (above linea terminalis) Upper flared parts of 2 iliac bones and concavities Wings of base of sacrum Passageway: Bony Pelvis (cont’d.) Pelvic shape Gynecoid: favorable for vaginal delivery Android: male-shaped, not favorable Anthropoid: usually adequate Platypelloid: not favorable Passageway: Soft Tissues Cervix Thins through effacement to allow presenting part to descend into vagina Pelvic floor muscles Vagina  Passenger Fetal skull Fetal attitude Fetal lie Fetal presentation Fetal position Fetal station Fetal engagement Passenger: Fetal Skull Largest and least compressible structure Sutures: allow for overlapping and Loading… changes in shape (molding); help identify position of fetal head Fontanels: intersections of sutures; help in identifying position of fetal head and in molding Diameters: occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal Passenger: Fetal Attitude Posturing—flexion or extension— of the joints Start of labor best position is all joints flexed Presents smallest fetal skull diameter to pelvis Passenger: Fetal Lie Longitudinal: Up and down Vertex (head down) Breech (butttocks) Transverse: Horizontal Oblique: Angled/slanted Provider can try and manipulate the positioning of the baby Passenger: Fetal Presentation Cephalic (vertex, flexed) Military (neutral neck) Brow Face Breech Frank Full or complete Footling or incomplete Shoulder Passenger: Fetal Position Landmarks Occipital bone (0): vertex presentation Chin (mentum [M]): face presentation Buttocks (sacrum [S]): breech presentation Scapula (acromion process [A]): shoulder presentation Three-letter abbreviation for identification (see Figure 13.9)  Passenger: Fetal Station Relationship of presenting part to maternal pelvic ischial spines -4 -3 No engagement -2 -1 0 - ENGAGEMENT +1 - DESCENT +2 - FLEXION +3 and +4 - INTERNAL ROTATION Passenger: Fetal Engagement Presenting part reaching 0 station Floating: no engagement; presenting part freely movable about pelvic inlet Cardinal Movements of Labor Engagement Descent Flexion Internal rotation Extension External rotation (restitution) Expulsion  Powers Uterine contractions (primary stimulus) Intra-abdominal pressure from mother pushing and bearing down Contractions: involuntary: thin and dilate cervix Three parameters Frequency (how often) Duration (how long they last) Intensity (strength)  Psychological Response Factors Influencing a Positive Birth Experience Clear information on procedures Support, not being alone Sense of mastery, self-confidence Trust in staff caring for her Positive reaction to the pregnancy Personal control over breathing Preparation for the childbirth experience  Physiologic Responses to Labor: Maternal Increased heart rate, cardiac output, blood pressure (during contractions) Increased white blood cell count Increased respiratory rate and oxygen consumption Decreased gastric motility and food absorption Decreased gastric emptying and gastric pH  Physiologic Responses to Labor: Maternal (cont’d.) Slight temperature elevation Muscle aches/cramps Increased BMR Decreased blood glucose levels Physiologic Responses to Labor: Fetal Periodic FHR accelerations and slight decelerations Decrease in circulation and perfusion Increase in arterial carbon dioxide pressure Decrease in fetal breathing movements Decrease in fetal oxygen pressure; decrease in partial pressure of oxygen  Stages of Labor First stage (see Table 13.2) True labor to complete cervical dilatation (10 cm) Longest of all stages Three phases Latent phase: 6-9 hrs; (0-3 cm, 0-40 %, cont 5-10 min, 30-45 sec) Active phase 4-6 hrs; (4-7 cm, 40-80%, cont 2-5 min, 45-60 sec) Transition phase 1/2 -1 hr; (8-10 cm, 80-100%, 1-2 min, 60-90 sec) Stages of labor (cont) Second stage: cervix 10 cm dilated to birth of baby- 1-3 hrs Cardinal movements, contractions 2-3 min, 60-90 sec Pelvic phase: fetal head descends Perineal phase: head distends the perineum, tremendous urge to push Crowning: head no longer regresses between contractions Spontaneous (waiting for natural instinct to push) vs directed pushing (starting sustained pushing as soon as cervix is dilated) Stages of Labor (cont’d.) Third stage: birth of infant to placental separation Placental separation Placental expulsion (up to 30 min) normal blood loss 500-1000 mL Fourth stage: 1 to 4 hours following delivery Signs of Placental Separation The uterus rises upward The umbilical cord lengthens A sudden trickle of blood is released from the vaginal opening The uterus changes its shape to globular Nursing Management of Laboring Women Assessment Comfort measures Emotional support Information and instruction Advocacy Support for the partner Maternal Assessment During Labor and Birth Maternal status (vital signs, pain, prenatal record review) Vaginal examination (cervical status, fetal descent and presentation); q 4 hrs Loading… dilation, effacement, membrane Rupture of membranes Feel for soft bulge, check for cord prolapse if ruptured Uterine contractions (see Figure 14.2)—external palpation Maternal assessment (cont) Leopold’s maneuvers (see Nursing Procedure 14.1)—presentation, position, lie 1—What fetal part felt at fundus? 2—On which maternal side is fetal back located? 3—What is the presenting part? 4—Is fetal head flexed and engaged?  Fetal Assessment During Labor and Birth Amniotic fluid analysis check fluid with nitrazine swab/strip—will be blue if amniotic fluid Fetal heart rate monitoring Handheld vs. electronic; intermittent vs. continuous; external vs. internal Fetal heart rate patterns Baseline, baseline variability, periodic changes (see Table 14.1) Other assessment methods Fetal scalp sampling, pulse oximetry, stimulation Key Terms Related to Fetal Heart Rate Accelerations Artifacts Baseline fetal heart rate Baseline variability Deceleration Electronic fetal monitoring Periodic baseline changes Guidelines for Assessing Fetal Heart Rate 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 low-risk women and every 15 minutes for high-risk women During second stage of labor intermittent auscultation every 15 minutes for low-risk women and every 5 minutes for high-risk women Continuous Electronic Fetal Monitoring Uses a machine to produce a continuous tracing of the FHR Produce a graphic record of the FHR pattern Primary objective To provide information about fetal oxygenation and prevent fetal injury from impaired oxygenation To detect fetal heart rate changes early before they are prolonged and profound  Criteria for Using Continuous Internal Monitoring of the FHR Ruptured membranes Cervical dilation of at least 2 cm Present fetal part low enough to allow placement of the scalp electrode Skilled practitioner available to insert spiral electrode (ICI, 2011). 4 Categories of Baseline Variability Absent: fluctuation range undetectable Minimal: fluctuation range observed at 25 beats per minute Interpreting FHR Patterns Normal=baseline 110-160 with variability of 5-25 bpm Early decelerations=fetal head compression, no interventions Late decelerations=uteroplacental insufficiency, fetal hypoxia, requires interventions Notify provider Reposition pt on side Discontinue Pitocin if it is running Increase IV fluid rate Administer O2: 8-10 L NRB Reassure patient Prepare for c-section if not corrected within 30 min  Factors Influencing Pain During Labor and Birth Physiologic Spiritual Psychosocial Cultural Environmental Comfort and Pain Management Pain as universal experience; intensity highly variable Mandate for pain assessment in all clients admitted to health care facility Numerous nonpharmacologic and pharmacologic choices available  Non-pharmacological Measures for Pain Management Continuous labor support Hydrotherapy Ambulation and position changes (see Table 14.2, Figure 14.9) Acupuncture and acupressure Attention focusing and imagery Therapeutic touch and massage; effleurage (abdominal massage) Breathing techniques (e.g., patterned-paced breathing) Hot/cold therapy Pharmacologic Measures Systemic analgesia Regional or local anesthesia Neuraxial analgesia/anesthesia techniques: use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space Shift in pain management: woman as an active participant during labor Systemic Analgesia Route: typically administered parenterally through existing IV line Drugs (see Drug Guide 14.1) Opioids (butorphanol, nalbuphine, meperidine, fentanyl) Ataractics (hydroxyzine, promethazine) Benzodiazepines (diazepam, midazolam) Regional Analgesia/Anesthesia Epidural block: continuous infusion or intermittent injection; usually started when dilation >5 cm Combined spinal-epidural block (“walking epidural”) Patient-controlled epidural Local infiltration (usually for episiotomy or laceration repair) Pudendal block (usually for 2nd stage, episiotomy, or operative vaginal birth) Intrathecal (spinal) analgesia/anesthesia (during labor and cesarean birth) General Anesthesia Emergency cesarean birth or woman with contraindication to use of regional anesthesia IV injection, inhalation, or both Commonly, first thiopental IV to produce unconsciousness Next, muscle relaxant Then intubation, followed by administration of nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia  First Stage of Labor: Phone EstimatedAssessment date of birth Fetal movement; frequency in past few days Other premonitory signs of labor experienced Parity, gravida, and previous childbirth experiences Time frame in previous labors Characteristics of contractions Bloody show and membrane status (whether ruptured or intact) Presence of supportive adult in household or if she is alone Nursing Care During First Stage of Labor General measures Obtain admission history Check results of routine laboratory tests and any special tests Ask about childbirth plan Complete a physical assessment Initial contact either by phone or in person  First Stage of Labor: Admission Assessment Maternal health history (see Fig. 14.13 & Box 14.2) Physical assessment (body systems, vital signs, heart and lung sounds, height and weight) Fundal height measurement Uterine activity, including contraction frequency, duration, and intensity Status of membranes (intact or ruptured) Cervical dilatation and degree of effacement Fetal heart rate, position, station Pain level  First Stage of Labor: Admission Assessment (cont’d.) Fetal assessment Lab studies Routine: urinalysis, CBC Syphilis screening, HbsAg screening, GBS, HIV (with woman’s consent), and possible drug screening if not included in prenatal history Assessment of psychological status  First Stage of Labor: Continuing Assessment Woman’s knowledge, experience, and expectations Vital signs Vaginal examinations Uterine contractions Pain level Coping ability FHR Amniotic fluid (see Table 14.3) Nursing Management: Second Stage Assessment Typical signs of 2nd stage Contraction frequency, duration, intensity Maternal vital signs Fetal response to labor via FHR Amniotic fluid with rupture of membranes Coping status of woman and partner  Nursing Management: Second Stage Interventions Supporting woman & partner in active decision making Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced Providing instructions, assistance, pain relief Using maternal positions to enhance descent and reduce pain Preparing for assisting with delivery  Nursing Management: Second Stage (cont’d.) Interventions with birth Cleansing of perineal area and vulva Assisting with birth, suctioning of newborn, and umbilical cord clamping Providing immediate care of newborn Drying Apgar score Identification  Nursing Management: Third Stage Assessment Placental separation; placenta and fetal membranes examination; perineal trauma; episiotomy; lacerations Interventions Instructing to push when separation apparent; giving oxytocin if ordered; assisting woman to comfortable position; providing warmth; applying ice to perineum if episiotomy; explaining assessments to come; monitoring mother’s physical status; recording birthing statistics; documenting birth in birth book  Nursing Management: Fourth Stage Assessment Vital signs, fundus, perineal area, comfort level, lochia, bladder status Interventions Support and information Fundal checks; perineal care and hygiene Bladder status and voiding Comfort measures Parent–newborn attachment Teaching