NUR 1210 Maternal Module 4 - Nursing Care During Labor & Delivery PDF

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM MODULE #4...

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM MODULE #4 – NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY INTRODUCTION Usually, labor and delivery occur without any problems. These problems can be anticipated and treated effectively. However, problems sometimes develop suddenly and unexpectedly. Regular visits to a doctor or certified nurse midwife during pregnancy make anticipation of problems possible and improve the chances of having a healthy baby and safe delivery. Dystocia is characterized by abnormally slow progress of labor. This is the most common indication of primary cesarean section. This is most common in primipara (25-30%) and multipara (10-15%). A difficult labor—dystocia—can arise from any of the four main components of the labor process: (a) the power, or the force that propels the fetus (uterine contractions), (b) the passenger (the fetus), (c) the passageway (the birth canal), or (d) the psyche (the woman’s and family’s perception of the event). Because complications can occur at any point in labor, continuous monitoring of a laboring woman and fetus and providing emotional support for her and her family are essential. The nurse should reassure a woman in labor that everything is going smoothly and that both she and her fetus appear to be doing well. If a complication arises, a woman needs someone who is knowledgeable about the deviation and its treatment as well as a person who understands her feelings of helplessness. Nurses play a key role in providing this type of skilled physical and emotional care. Some problems develop or become obvious during labor or delivery. Such problems include amniotic fluid embolism (the fluid that surrounds the fetus in the uterus enters the woman’s bloodstream, sometimes causing a life-threatening reaction in the woman), shoulder dystocia (the fetus's shoulder lodges against the woman's pubic bone, and the baby is caught in the birth canal), labor that starts too early, the umbilical cord comes out of the birth canal before the baby) and the like. When complications develop, alternatives to spontaneous labor 1|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM and vaginal delivery may be needed. They include induction of labor, operative vaginal delivery (forceps or vacuum extractor) and caesarean delivery. LEARNING OUTCOMES: After the successful completion of the module you should be able to: LO1 Integrate concepts, theories and principles of sciences and humanities in the formulation and application of appropriate nursing care to mothers with complications during labor and delivery to achieve quality maternal and child nursing care. LO2 Apply maternal and child nursing concepts and principles in the prevention of complications during labor and delivery that place the woman and her fetus at high risk. holistically and comprehensively. LO3 Assess mothers who is experiencing complication during labor and delivery with the use of specific methods and tools to address existing health needs. LO4 Formulate nursing diagnoses to address needs / problems of mothers and her family experiencing complication during labor and delivery. LO5 Implement safe and quality nursing interventions to meet the needs and promote optimal outcomes for mothers and her family during a complication of labor and delivery. LO7 Evaluate with mothers and family the expected outcomes for the effectiveness and achievement of care. LO8 Institute appropriate corrective actions to prevent or minimize complications during labor and delivery. 2|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM TOPIC OUTLINE: Nursing Care of the Client with High-Risk Labor & Delivery and her Family 1. Problems of the Passenger 1) Fetal malposition a. Types of fetal malposition b. Nursing care c. Medical Management 2) Fetal malpresentation a. Vertex malpresentation a) brow presentation b) face presentation c) sincipital presentation b. Breech presentation a) types b) maternal risks c) vagina evolving of breech d) external/podalic version c. Shoulder presentation d. Compound presentation e. Nursing /Medical care of client with malpresentation 3) Fetal distress a. causes b. signs/symptoms c. nursing interventions 4) Prolapse umbilical cord a. cause b. contributing factors c. assessment & nursing diagnoses d. nursing interventions 2. Problems with the passageway 1) abnormal size or shape of the pelvis a. cephalopelvic disproportion b. shoulder dystocia c. nursing care of client with problems of the passageway 3|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM 3. Problems with the Powers 1) dystocia or difficult labor a. hypertonic uterine dysfunction b. hypotonic uterine dysfunction c. abnormal progress in labor d. retraction rings e. premature labor f. precipitate labor and birth g. uterine rupture 4. Placenta problems 1. Implantation in the lower uterine segment 2. Premature detachment of placenta CONTENT PROBLEMS WITH THE PASSENGER Birth complications may arise if an infant is immature or preterm. Complications may also occur if the maternal pelvis is so undersized, such as occurs in early adolescence or in women with altered bone growth from a disease such as rickets that its diameters are smaller than the fetal skull diameters. It also can occur if the umbilical cord pro- lapses, if more than one fetus is present, or if a fetus is malpositioned or too large for the birth canal. Problems with Fetal Position, Presentation, or Size Occipitoposterior Position In approximately one tenth of all labors, the fetal position is posterior rather than anterior. That is, the occiput is directed diagonally and posteriorly, either to the right (ROP) or to the left (LOP). In these positions, during internal rotation, the fetal head must rotate, not through a 90-degree arc, but through an arc of approximately 135 degrees. Rotation from a posterior position can be aided by having the woman assume a hands and knees position, 4|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM squatting, or lying on her side (on her left side if the fetus is right occiput posterior; on her right side if the fetus is left occiput posterior). Posterior positions tend to occur in women with android, anthropoid, or contracted pelvis. A posterior position is suggested by a dysfunctional labor pattern such as a prolonged active phase, arrested descent, or fetal heart sounds heard best at the lateral sides of the abdomen. A posteriorly presenting head does not fit the cervix as snugly as one in an anterior position. Because this increases the risk of umbilical cord prolapse, the position of the fetus is confirmed by vaginal examination or by ultrasound. The majority of fetuses presenting in posterior positions, if they are of average size and in good flexion and aided by forceful uterine contractions, rotate through the large arc, arrive at a good birth position for the pelvic outlet, and are born satisfactorily with only increased molding and caput formation. 5|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Because the fetal head rotates against the sacrum, a woman may experience pressure and pain in her lower back owing to sacral nerve compression. These sensations may be so intense that she asks for medication for relief, not for her contractions but for the intense back pressure and pain. Applying counterpressure on the sacrum by a back rub may be helpful in relieving a portion of the pain. Applying heat or cold, whichever feels best, also may help. Lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus rotate. The fetal head may arrest in the transverse position (transverse arrest), or rotation may not occur at all (persistent occipitoposterior position). In these instances, the fetus must be born by cesarean birth. 6|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Breech Presentation Most fetuses are in a breech presentation early in pregnancy. However, by week 38, a fetus normally turns to a cephalic presentation. Although the fetal head is the widest single diameter, the fetus’s buttocks (breech), plus the legs, actually take up more space. There are several types of breech presentation: complete, frank, and footling. Breech presentation is more hazardous to a fetus than a cephalic presentation, because there is a higher risk of: Anoxia from a prolapsed cord Traumatic injury to the aftercoming head (possibility of intracranial hemorrhage or anoxia) Fracture of the spine or arm Dysfunctional labor Early rupture of the membranes because of the poor fit of the presenting part Causes of Breech Presentation Gestational age less than 40 weeks Abnormality in a fetus, such as anencephaly, hydrocephalus, or meningocele. Hydramnios that allows for free fetal movement, so that the fetus fits within the uterus in any position Congenital anomaly of the uterus, such as a mid-septum, that traps the fetus in a breech position Any space-occupying mass in the pelvis, such as a fibroid tumor of the uterus or a placenta pre-via, that does not allow the head to present Pendulous abdomen. If the abdominal muscles are lax, the uterus may fall so far forward that the fetal head comes to lie outside the pelvic brim, causing a breech presentation. Multiple gestation. The presenting infant cannot turn to a vertex position. Unknown factors 7|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Assessment With a breech presentation, fetal heart sounds usually are heard high in the abdomen. Leopold’s maneuvers and a vaginal examination usually reveal the presentation. If the presentation is unclear, ultrasound clearly confirms a breech presentation. In a breech birth, the same stages of flexion, descent, internal rotation, expulsion, and external rotation occur as in a vertex birth. Always monitor FHR and uterine contractions continuously, if possible, during this time. This allows early detection of fetal distress from a complication such as prolapsed cord and allows for prompt intervention. Birth Technique If the infant will be born vaginally, a woman is allowed to push after full dilatation is achieved, and the breech, trunk, and shoulders are born. As the breech spontaneously emerges from the birth canal, it is steadied and supported by a sterile towel held against the infant’s inferior surface. The shoulders present to the outlet with their widest diameter anteroposterior. If they are not born readily, the arm of the posterior shoulder may be drawn down by passing two fingers over the infant’s shoulder and down the arm to the elbow, then sweeping the flexed arm across the infant’s face and chest and out. The other arm is delivered in the same way. External rotation is allowed to occur, to bring the head into the best outlet diameter. Birth of the head is the most hazardous part of a breech birth. Because the umbilicus precedes the head, a loop of cord passes down alongside the head. The pressure of the head against the pelvic brim automatically compresses this loop of cord. A second danger of a breech birth is intracranial hemorrhage. With a breech birth, pressure changes occur instantaneously. Tentorial tears, which can cause gross motor and mental incapacity or lethal damage to the fetus, may result. To aid in birth of the head, the trunk of the infant is usually straddled over the physician’s right forearm. Two fingers of the physician’s right hand are placed in the infant’s mouth. The left hand is slid into the woman’s 8|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM vagina, palm down, along the infant’s back. Pressure is applied to the occiput to flex the head fully. Gentle traction applied to the shoulders (upward and outward) delivers the head. An aftercoming head may also be delivered by the aid of Piper forceps to control flexion and the rate of descent. The difficulty with birth of the head is the reason why planned cesarean birth is the usual method of birth for many breech-presentation infants today. Face Presentation A fetal head presenting at a different angle than expected is termed asynclitism. Face (chin, or mentum) presentation is rare, but when it does occur, the head diameter the fetus presents to the pelvis is often too large for birth to proceed. A head that feels more prominent than normal, with no engagement apparent on Leopold’s maneuvers, suggests a face 9|P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM presentation. It is also suggested when the head and back are both felt on the same side of the uterus with Leopold’s maneuvers. The back is difficult to outline in this presentation because it is concave. If the back is extremely concave, fetal heart tones may be transmitted to the forward-thrust chest and heard on the side of the fetus where feet and arms can be palpated. A face presentation is confirmed by vaginal examination when the nose, mouth, or chin can be felt as the presenting part. A fetus in a posterior position, instead of flexing the head as labor proceeds, may extend the head, resulting in a face presentation; this usually occurs in a woman with a contracted pelvis or placenta previa. It also may occur in the relaxed uterus of a multipara or with prematurity, hydramnios, or fetal malformation. If the chin is anterior and the pelvic diameters are within normal limits, it may be possible for the infant to be born without difficulty (perhaps after a long first stage of labor, because the face does not mold well to make a snugly engaging part). If the chin is posterior, cesarean birth is usually the method of choice; otherwise, it would be necessary to wait for a long posterior-to-anterior rotation to occur. Brow Presentation A brow presentation is the rarest of the presentations. It occurs in a multipara or a woman with relaxed abdominal muscles. It almost invariably results in obstructed labor, because the head becomes jammed in the brim of the pelvis as the occipitomental diameter presents. Unless the presentation spontaneously corrects, cesarean birth will be necessary to birth the infant safely. Brow presentations also leave an infant with extreme ecchymotic bruising on the face. Transverse Lie Transverse lie occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. It may occur in infants with hydrocephalus or another abnormality that prevents the head from engaging. It may also occur in prematurity if 10 | P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM the infant has room for free movement, in multiple gestation (particularly in a second twin), or if there is a short umbilical cord. A transverse lie usually is obvious on inspection, because the ovoid of the uterus is found to be more horizontal than vertical. The abnormal presentation can be confirmed by Leopold’s maneuvers. An ultrasound may be taken to further confirm the abnormal lie and to provide information on pelvic size. Cesarean birth is necessary. Oversized Fetus (Macrosomia) Size may become a problem in a fetus who weighs more than 4000 to 4500 g (approximately 9 to 10 lb). Babies of this size complicate up to 10% of all births and are most frequently born to women who enter pregnancy with diabetes or develop gestational diabetes. Large babies are also associated with multiparity, because each infant born to a woman tends to be slightly heavier and larger than the one born just before. An oversized infant may cause uterine dysfunction during labor or at birth because of overstretching of the fibers of the myometrium. The wide shoulders may pose a problem at birth, because they can cause fetal pelvic disproportion or even uterine rupture from obstruction. If the infant is so oversized that he or she cannot be born vaginally, cesarean birth becomes the birth method of choice. Prolapse of the Umbilical Cord In umbilical cord prolapse, a loop of the umbilical cord slips down in front of the presenting fetal part. Prolapse may occur at any time after the membranes rupture if the presenting fetal part is not fitted firmly into the cervix. It tends to occur most often with: Premature rupture of membranes Fetal presentation other than cephalic Placenta previa Intrauterine tumors preventing the presenting part from engaging A small fetus 11 | P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Cephalopelvic disproportion preventing firm engagement Hydramnios Multiple gestation Assessment The cord may be felt as the presenting part on an initial vaginal examination during labor. It may also be identified in this position on an ultrasound. When this happens, cesarean birth is necessary before rupture of the membranes occurs. Otherwise, membrane rupture would cause the cord to slide down into the vagina from the pressure exerted by the amniotic fluid. Cord prolapse is first discovered only after the membranes have ruptured, when a variable deceleration FHR pattern suddenly becomes apparent. The cord may be visible at the vulva. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy. Therapeutic Management Cord prolapse automatically leads to cord compression, because the fetal presenting part presses against the cord at the pelvic brim. Management is aimed at relieving pressure on the cord, thereby relieving the compression and the resulting fetal anoxia. This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord, or by placing the woman in a knee–chest or Trendelenburg position, which causes the fetal head to fall back from the cord. Administering oxygen at 10 L/min by face mask to the woman is also helpful to improve oxygenation to the fetus. A tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus. If the cord has prolapsed to the extent that it is exposed to room air, do not attempt to push any exposed cord back into the vagina. Instead, cover any exposed portion with a sterile saline compress to prevent drying. 12 | P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM If the cervix is fully dilated at the time of the prolapse, the physician may choose to birth the infant quickly, possibly with forceps, to prevent fetal anoxia. If dilatation is incomplete, the birth method of choice is upward pressure on the presenting part, applied by a practitioner’s hand in the woman’s vagina, to keep pressure off the cord until the baby can be born by cesarean birth. Multiple Gestation Twins may be born by cesarean birth to decrease the risk that the second fetus will experience anoxia; this also is often the situation in multiple gestations of three or more, because of the increased incidence of cord entanglement and premature separation of the placenta. Multiple pregnancies often end before full term, because the babies are usually small, firm head engagement may not occur, increasing the risk for cord prolapse after rupture of the membranes. Because of the multiple fetuses, abnormal fetal presentation may occur. Uterine dysfunction from a long labor, an overstretched uterus, unusual presentation, and premature separation of the placenta after the birth of the first child may also be more common. Most twin pregnancies present with both twins vertex. This is followed in frequency by vertex and breech, breech and vertex, and then breech and breech. Multiple gestations of three or more fetuses have extremely varied presentations. After the first infant is born, both ends of the baby’s cord are tied or clamped permanently, rather than with cord clamps, which could slip. This prevents hemorrhage through an open cord end if additional infants have shared the placenta. After the birth of the first child, the lie of the second fetus is determined by external abdominal palpation or ultrasound. If the presentation is not vertex, external version may be attempted to make it so. If this is not successful, a decision for a breech birth or cesarean birth must be made. If the infant will be born vaginally, an oxytocin infusion may be begun at this point to assist uterine contractions, thereby shortening the time span between births. If uterine relaxation is needed, nitroglycerin, an uterine relaxant, may be administered. Assess the woman carefully in the immediate postpartal period, because the uterus that has been overly 13 | P a g e NUR 1210 – MATERNAL CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH) Prepared by MCN FEU Faculty Lecturers January 2021  FAR EASTERN UNIVERSITY INSTITUTE OF NURSING FIRST SEMESTER – AY 2024 – 2025 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM distended owing to the multiple gestation may have more difficulty contracting than usual, placing her at risk for hemorrhage from uterine atony. In addition, the risk for uterine infection increases if labor or birth was prolonged. The infants need careful assessment to determine their true gestational age and whether a phenomenon such as twin-to- twin transfusion could have occurred. PROBLEMS WITH THE PASSAGEWAY Still another reason that dystocia can occur is a contraction or narrowing of the passageway or birth canal. This can happen at the inlet, at the midpelvis, or at the outlet. The narrowing causes CPD, or a disproportion between the size of the fetal head and the pelvic diameters. This results in failure to progress in labor. Inlet Contraction Inlet contraction is narrowing of the anteroposterior diameter to less than 11 cm, or of the transverse diameter to 12 cm or less. The anteroposterior diameter of the inlet is commonly approximated by manually measuring the diagonal conjugate, which is approximately 1.5 centimeter greater. Therefore, inlet contraction is usually defined as a diagonal conjugate