In Class Reproduction, Perfusion, and Intrapartum Pain PDF

NUR 339 Concept Reproduction, Perfusion, & Pain in the Intrapartum Period Creighton University College of Nursing Sarah Ball PhD, RNC-OB, C-EFM College of Nursing  Objectives Identify physiologica...

NUR 339 Concept Reproduction, Perfusion, & Pain in the Intrapartum Period Creighton University College of Nursing Sarah Ball PhD, RNC-OB, C-EFM College of Nursing  Objectives Identify physiological signs & symptoms of impending & the onset of labor. Differentiate stages & phases of the intrapartum period. Recognize and summarize findings for cervical dilation, effacement, station & fetal presentation. Develop a plan utilizing the care management process for a low-risk intrapartum client and her support network. Evaluate basic intrapartum fetal & maternal surveillance data Formulate nursing interventions based on fetal and maternal variances during the intrapartum period. Understand appropriate comfort with non-pharmacological & pharmacological interventions for the low-risk intrapartum client. 2  Population-Based Outcomes Progression of labor without complications Stabilization of mother and fetus/newborn Pain perception will be manageable Safe delivery of a healthy neonate/newborn Postpartum recovery will be free from complications 3  Estrogen and Progesterone Structure Estrogen Effects Progesterone Effects Breasts Growth of Ducts; promotes Growth of lobules and alveoli; prolactin effects inhibits prolactin effects Vaginal Mucosa Squamous epithelium Squamous epithelium thinning; proliferation, ↑ glycogen content cellular decornification of cells; cellular cornification Cervical Mucosa Produces secretions favoring Produces secretions tending to plug survival; enhances sperm motility the cervical os Fallopian Tube ↑ motility & ciliary action ↓ motility & ciliary action Uterine Muscle ↑ blood flow, ↑ contractile Relaxes myometrium, ↓ oxytocin proteins, uterine muscle & sensitivity myometrial excitability & action potential, ↑ oxytocin sensitivity Endometrium Stimulates growth, ↑ number of Activates glands & blood vessels, ↓ progesterone receptors number of estrogen receptors  Anatomy of Late Pregnancy Uterus – – Muscular Organ – Supported by ligaments – Composed of two major parts Cervix – lower cylindric portion Fundus – dome-shaped top of the uterus – Uterine Wall (3 layers) Endometrium Myometrium Peritoneum 5  Non-Pregnant Vs Pregnant Uterus 6  Pregnancy – Placenta Perfusion Placenta – Begins to form on implantation – Maternal-Placental-Embryonic circulation is in place by day 17 – Exchange of oxygen and nutrients with carbon dioxide and waste products through the maternal blood supply – Functions as an endocrine gland – producing hormones necessary to maintain the pregnancy and support the embryo and fetus hCG, hCs 7  Placenta Perfusion 8  Pregnancy Perfusion – Umbilical Cord Umbilical Cord – Forms by day 14 – Consists of two arteries and one vein (AVA) – Increases in length throughout the pregnancy At term the cord is 2 cm in diameter and an average of 55 cm long 9  Fetal Membranes Chorion – outermost membrane that surrounds the amnion and developing embryo Amnion – Contains the amniotic fluid – Amnion and Chorion form the amniotic sac Amniotic Fluid – derived by diffusion from the maternal blood – Increases weekly – Volume constantly changes – Multi-functional – Oligohydramnios – less than 300 mL – Hydramnios (polyhydramnios) – more than 2L 10  Amniotic Fluid Maintains constant body temperature Serves as a source of oral fluid and a repository for waste Assists in maintenance of fluid and electrolyte hemostasis Allows freedom of movement for musculoskeletal development Cushions of the fetus from trauma by blunting and dispersing outside forces Acts as a barrier to infection and Allows fetal lung development 11  Amniotic Fluid - Assessment Amniotic Fluid vs. Urine – Nitrazine Paper (pH paper) Time of Rupture – Response of fetus Type of Rupture – SROM – Spontaneous Rupture of Membranes – AROM – Artificial Rupture of Membranes – PROM – Premature Rupture of Membranes – PPROM – Preterm Premature Rupture of Membranes 12  Amniotic Fluid – “ COAT” Assessment Color – Clear Routine Monitoring – Meconium Stained Indicates Fetal Stress/Maturity Requires Closer Observation – Port Wine Stained Possible placental complication Requires Closer Observation Odor Amount Temperature – Increase frequency of assessment at least every 2 hr 13  Labor - Causes Cannot be attributed to a single cause Hormonal influence – Increase in Oxytocin – Increase in Estrogen – Increase in Prostaglandins – Decrease in Progesterone Uterine Distention and Increased Intrauterine Pressure 14  Factors Affecting Labor: The “Five P’s” Passenger Passageway Powers Position Psychology 15  Passenger – Fetal Head Size of fetal head – Bones, Sutures and Fontanels Molding – slight overlapping of the fetal skull bones which occurs during labor Figure 16 -1 16  Passenger: Fetal Presentation Presentation – part of the fetus that enters the pelvic inlet first – Cephalic – head Vertex Preferred Variances- Military, brow, face – Breech – buttocks, feet or both Most commonly requires external version or cesarean section – Shoulder 17  Cephalic Presentation vertex military brow face Complete Frank Footling  Passenger – Fetal Lie Lie – the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother – Longitudinal/vertical – long axis of the fetus is parallel with the long axis of the mother – Transverse/horizontal/oblique – long axis of the fetus is at a right angle diagonal to the long axis of the mother 20  Passenger – Fetal Attitude Attitude – the relation of the fetal body parts to each other 21  Passenger – Fetal Position Position – the relationship of a reference point on the presenting part (occiput, sacrum, mentum [chin]) to the four quadrants of the mother’s pelvis – Engagement – Station 22  Passageway Two components: – Mother’s bony rigid pelvis – Soft Tissues of the cervix, the pelvic floor, the vagina and the introitus Assessment – Often occurs at the first prenatal visit and at the admission when in labor 24  Powers: Primary Involuntary contractions originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment Contractions – Frequency – time from the beginning of one contraction to the beginning of another – Duration – beginning to end of one contraction – Intensity – Strength of the contraction 25  Primary Powers Effacement – shortening and thinning of the cervix during the first stage of labor – Expressed in percentages Dilation – enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun – Expressed in cm’s – Ferguson’s Reflex – occurs upon complete dilation and is the maternal urge to bear down 26 Assessment   Powers: Secondary Utilizing of bearing-down efforts to aid in the expulsion of the infant from the uterus and vagina after the cervix is fully dilated Valsalva Maneuver – closed glottis and prolonged bearing down Open-glottis pushing Delayed pushing Position 29  Positions during Labor 30  Psychological Response Pain Response Environment Anxiety/Fear Breathing/Relaxation Expectation 31  Signs Preceding Labor Lightening – fetus’s presenting part descends into the true pelvis Urinary Frequency returns Back pain Braxton Hicks – more frequent and stronger Weight Loss of 0.5 to 1.5 kg (3.5 lbs) Surge of energy – “Nesting” Cervical ripening – Increased vaginal discharge (mucous plug/bloody show) – Possible Rupture of Membranes 32  True vs. False Labor True False Contractions Contractions Become Regular with Increase Do not increase in frequency, frequency, intensity & duration intensity, duration; may be regular or irregular Not relieved by ambulation or Relief with ambulation or comfort measures comfort measures Cervix Changes in Cervix Dilation & Effacement No significant change Decent of baby 33  Admission Assessment Name Obstetrical History Age – Prenatal Lab Work EDC – GBS GTPAL – Weight Gain – Current Medications Fetal Movement Medical Surgical History Membrane Status – Color of Amniotic fluid Physical Abuse Pain Substance Abuse Allergies Immunization Status 34  Admission Considerations Interpreter Support Person(s) Childbirth Education Special Requests/Birth plans Newborn Feeding Preference Pictures Newborn Immunizations 35  Fetal & Maternal Assessments, Diagnostics and Screenings Electronic Fetal Monitoring OB Assessments – Leopold’s Maneuvers – Sterile Vaginal Examination – Uterine Activity – Nitrazine/Ferning/ Speculum Assessment Examination – Vital Signs – Ultrasound – Head to Toe CBC – Deep Tendon Reflexes, – WBC Clonus – Hgb/Hct – Edema Assessment 36  Nursing Diagnoses (Normal Labor) Anxiety Risk for Post-Trauma Impaired Comfort Syndrome Fatigue Risk for Powerlessness Deficient Knowledge Readiness for enhanced Acute Pain Childbearing Process Tissue Integrity Readiness for enhanced Family Coping Risk for deficient Fluid Readiness for enhanced Volume Power Risk for Infection Readiness for enhanced Risk for Injury Self-Health Management 37  Stages of Labor Stage 1- contractions to full effacement & dilatation Stage 2 –Complete dilatation to Birth of fetus Stage 3- Birth of fetus to Delivery of placenta Stage 4- Delivery of placenta to 2 hours after  Stages of Labor – Stage 1 Phase One - Latent Dilation: 0-3 cm Ctx: freq 5 - 30 min Duration: 30-45 sec  Nursing Support – First Stage Assessment Latent Phase Active Phase Transition Phase BP; Pulse; 30 – 60 min 30 min 15 – 30 min Respirations Temperature (Intact) 4 hours 4 hours 4 hours Temperature 2 hours 2 hours 2 hours (Ruptured/Febrile) Fetal Heart Rate and 30 - 60 min 15 – 30 min 15 – 30 min Pattern Uterine Activity 30 – 60 min 15 – 30 min 10 – 15 min Vaginal Discharge 30 – 60 min 15 – 30 min 10 – 15 min Vaginal Examination As Needed As Needed As Needed Mood; Affect; 30 min 15 min 5 min Energy Level  Induction of Labor Bishop Score – Calculation based upon dilation, effacement, station cervical consistency and cervical position 41  Augmentation/Induction of Labor Defined as: Initiation of uterine contractions before spontaneous onset birth Ripening Methods – Chemical Agents – Prostaglandins – Mechanical Agents- Foley Bulb Synthetic Oxytocin – stimulates contractions 42  Augmentation/Induction of Labor Amniotomy- artificial rupture of membranes – Risk for Cord Prolapse – Patient needs to stay in bed and be monitored Nipple Stimulation Use of herbs (black cohosh, castor oil) Stripping of the Membranes 43  Oxytocin (Pitocin) Natural hormone produced by the posterior pituitary Stimulates uterine contractions and aids in milk let-down – Causes excitability of the muscle cells present in the myometrial increasing the strength of the muscle and contraction The goal of oxytocin use is to produce contractions of normal intensity, duration and frequency using the lowest dose possible 44  Oxytocin When is oxytocin/Pitocin used during the labor and delivery process? 45  Labor – Vital Signs BP –↑ during contractions and returns to baseline between (systolic increased more than diastolic values) HR– Pulse ↑ in first and second stage of labor Cardiac Output - ↑10 – 15% in first stage; ↑30 – 50% in second stage Body Temperature - ↑ slightly Respiratory Rate and Pattern - ↑ rate Blood Glucose - ↓ Proteinuria – May be Present Gastric Motility and absorption - ↓ - nausea and vomiting may occur during transition to second stage 46  Fetal Monitor Assessment “Dr. C Bravado” Electronic Fetal Monitoring (EFM) – External – Internal (Scalp Electrode) Heart Rate – Normal: 110 – 160 bpm – Tachycardia: >160 bpm Causes: – Bradycardia: