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6.1a First Stage of Labor Flashcards

1
Q

First Stage of Labor

A
  • Begins with onset of contractions and ends with complete dilation and effacement
Latent
- Regular, painful uterine contractions causing cervical change
- 0-6 cm dilation
Active
- Greatest rate of cervical dilation
- Begins at 6 cm
- Ends at 10 cm
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2
Q

Assessment

A
  • Begins at first contact with patient
  • Minimize anxiety by explaining terms commonly used in labor

Relevant Data to Document

  • Prenatal record
  • Initial interview
  • Physical exam to establish baseline (vitals)
  • Lab and diagnostic results
  • Psychosocial and Cultural factors
  • Evaluation of labor status
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3
Q

True Labor

A

Contractions

  • Occur regularly and become stronger, last longer, occur closer together
  • Become more intense when walking
  • Felt in lower back radiating to lower abdomen
  • Continue despite comfort measures
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4
Q

False Labor

A
  • Irregular and only regular temporarily
  • Often stop when walking or changing position
  • Felt in back “or” abdomen above umbilicus
  • Can be stopped with use of comfort measures
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5
Q

Prenatal Data

A
  • Identifies needs and risks
  • Usually done during 3rd trimester
  • If there are no records, nurse will need to obtain baseline information
  • Ask questions between contractions if patient is in discomfort
  • Partner/Support person can be a secondary source of information
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6
Q

Emergency Medical Treatment and Active Labor Act (EMTALA)

A
  • Patients who are having contractions or may be in labor are considered unstable.
  • They must be assessed, stabilized, and treated at the hospital where they are present regardless of insurance or ability to pay.

The Nurses Role
- Providing services to patients when they experience pregnancy problem
(labor, decreased fetal movement, rupture of membranes)
- Document all information
(Assessment, interventions implemented, client response to care)

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7
Q

Prenatal Factors to Tailor Care

A
  • Age
  • Height and Weight
  • General Health Status
  • Current Medical Conditions
  • Allergies
  • Respiratory Status
  • Previous Surgical Procedures
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8
Q

Prenatal Records

A
  • Should always occur upon admittance to the facility
    HISTORY
  • Gravidity (Number of Pregnancies)
  • Parity (Number given birth above 20 weeks whether alive or not)
  • Problems (bleeding, hypertension, gestational diabetes, infection, EDB)
  • Patterns of weight gain
  • VS, fundal height, Baseline FHR, Lab/Test results
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9
Q

Common Diagnostic and Fetal Assessments

A
  • Amniocentesis (testing sample of amniotic fluid)
  • Non-stress test (NST) - Assess fetal heart rate and oxygen supply (overall baby health)
  • Biophysical Profile (BPP) - Measures fetal heart rate in response to movement. Combines nonstress test with ultrasound
  • Ultrasound Examination
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10
Q

Assessment

A

If patient had previous births the below must be noted

  • Characteristics of previous labor
  • Types of pain relief used
  • Type of birth (c-section, vacuum assisted, forceps assisted, vaginal)
  • Condition of newborn
  • Patients perception of previous labor and birth
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11
Q

Interview

A
  • Determine primary reason for coming to hospital
  • Auscultate and assess respiratory status (asthma which may affect general anesthesia)
  • Allergies including latex and tape
  • Routinely used medications in OB
  • Time and type of most recent solid/liquid intake
  • Birth plan
  • Type of pain management
  • Choice of infant feeding method
  • Name of pediatric provider
  • Preparations made for childbirth
  • Support person or family member who will be available
  • Cultural needs
  • Alcohol/Tobacco use
  • Plans for preserving memories such as photos and videotaping
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12
Q

Triage

A
  • Determine status of amniotic membrane
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13
Q

Sterile Speculum Examination and Nitrazine (pH)

A
  • Cotton tip swab to test pH of fluid.
  • Amniotic fluid is alkaline
  • Urine/purulent material is acidic
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14
Q

Fern Test

A
  • Determines if membranes have ruptured by getting a sample of cervical mucus smears
  • When estrogen is elevated smears form a fern like pattern
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15
Q

Bloody Show

A
  • Pink and sticky discharge
  • Sign of labor

Brownish/bloody discharge may be caused by vaginal examination or coitus

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16
Q

MATERNAL TRIAGE CLASSIFICATIONS

A
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17
Q

STAT/Priority 1

A
  • > 130 or <40 HR, SPO2 <93%, BP 150+/110+, <60HR, No FHR, FHR <110
  • Cardiac compromise
  • Severe respiratory distress
  • Seizing/Hemorrhaging
  • Placental Abruption/Uterine Rupture
  • Mental status change/Cannot follow verbal commands
  • Prolapsed cord
  • Active bearing down
  • Fetal parts visible on perineum
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18
Q

Urgent/Priority 2

A 
HR >120 or <50, Temperature >101.0, RR >26 or <12, SPO2 <95, BP 140+/90+ symptomatic, FHR 160+ for 60+ seconds
- Severe pain greater or equal to 7 
- High risk medical condition
- Difficulty breathing
- Altered Mental Status
- Suicidal/Homicidal
- <34 week SROM leaking or spotting 
- Active vaginal bleeding (not spotting or show) 
- Decreased fetal movement
- Recent Trauma
- SROM Leakage including
(HIV, Breech, Multiple gestation, Placental Previa)
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19
Q

Prompt/Priority 3

A
  • Temp >100.4, BP 140+/90+ asymptomatic
  • Signs of active labor >34 weeks
  • Early signs of labor
  • Woman is not coping
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20
Q

Non-Urgent/Priority 4

A
  • Common discomfort
  • Vaginal discharge
  • Constipation
  • Ligament pain
  • Nausea
  • Anxiety
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21
Q

Scheduled/Priority 5

A
  • Prescription refills

- Missed outpatient services

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22
Q

Postural Management (Position)

A
  • Non-cephalic positions are risky (breech, transverse)

- Should be corrected before engagement but close enough to term where position will be maintained

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23
Q

External Cephalic Version (ECV)

A
  • Ultrasound guided hands on procedure to manipulate fetus into cephalic lie
  • Done at 36-37 weeks of gestation
  • If preformed at 34-36 weeks, it can significantly increase chances of baby being born in cephalic presentation.
  • Beta stimulants are used to relax the uterus
  • Most successful is multiparous women with adequate amniotic fluid
  • Small risks for ECV
  • All women with breech position should be offered this
  • Positioning women with pelvis elevated is not shown to work
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24
Q

Early Phase of Labor

A
  • 0-5cm dilation
  • Nulliparous and Multiparous progress at similar rates
  • Mild to moderate contractions
  • 2-30 minutes apart
  • 30-40 seconds duration
  • No descension
  • Brown discharge of mucus plug (scant)
  • Patient is excited, able to walk
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25
Active Phase of Labor
- 6-10 cm dilation - Multiparous women progress quicker than nulliparous - Moderate to strong contractions - Pink/bloody mucus (moderate) - Becomes serious and doubtful to pain response
26
Sexual Abuse
- Labor can trigger memories especially during intrusive procedures - Ask permission to touch patient - Limit number of people interacting with patient - Explain all procedures - Avoid words such as "open your legs" or "relax it wont hut" - Limit invasive procedures - Have patient choose a person to be with her during labor
27
Stress of Labor
- Related to how well they prepared for childbearing - Dysfunctional relationships can cause feeling of guilt or failure - Encourage patient to express their feelings and fears related to labor (especially important for primigravida patients who have not attended birth classes and attainted information on the internet) - Multiparous women who have had negative experiences in the past also should discuss feelings - Concerns include maternal/fetal well-being and actions/attitude of healthcare staff
28
Cultural Factors
- Encourage patients to request specific practices important to her
29
Non-English speaking Women
- Anxiety increases when she does not understand what is going on - Family members are prohibited from being a translator - Bilingual nurses and interpreters can be used
30
Physical Examination
- General Systems - Fetal Status - Uterine Contractions - Vaginal Examination - These serve as a baseline
31
Early Labor Examination
- Temperature every 4 hours until membrane rupture. Then every 2 hours - BP, Pulse, RR, UA, FHR, Bloody show every 30-60 minutes - Changes in maternal appearance, mood, energy, involvement every 30 minutes
32
Active Labor Examination
- BP, Pulse, RR, UA, FHR, Bloody show every 15 minutes | - Maternal appearance, mood, energy, involvement of partner every 5-15 minutes
33
General Systems Assessment
- Heart - Lung - Skin - Edema in Face/Hands/Sacrum/Legs - DTR - Clonus (involuntary contractions) - Weight
34
Vitals
- BP every 30 minutes if elevated between contractions | - Body temperature to identify infection or fluid deficit
35
Leopold Maneuvar
- Used to see fetal presentation/lie and fetal size
36
Fundus Assessment
- Head feels round, firm, freely moveable - Breech is irregular and softer - Identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech)
37
Abdominal Sides Assessment
- Identify where the fetal back and arms are | - This identifies fetal presentation (Left, Anterior, Cephalic)
38
FHR Pattern Assessment
- Point of Maximum Intensity (PMI) - Usually directly over the fetus's back VERTEX POSITION - Heard below the umbilicus BREECH POSITION - Heard above the umbilicus - Important to measure FHR after rupture of membranes due to umbilical cord prolapse - Prolapse can also occur during changes in contraction pattern, maternal status, or before/after patient receives medication, or when procedure is preformed.
39
Uterine Contraction Assessment
- UA is not directly related to labor progress - Primary force to expel fetus (involuntary) Frequency - How often contractions occur Intensity - Strength of contraction Duration - Time between onset and end Resting Tone - Relaxation of uterus (tension between contractions)
40
Intensity
Mild - Easy to indent with fingertips (Pressing finger against nose) Moderate - Firm fundus, difficult to indent (Pressing finger against chin) Strong - Board like fundus (Pressing finger to forehead) - IUPC most accurate way of assessing intensity - Upon admission, monitored for 20-30 min to establish baseline
41
Vaginal Examination
- Determine true labor and rupture of membranes - Should be done as infrequently as possible - On admission - Prior to medication administration - Significant change in uterine activity - Maternal request (perineal pressure or urge to bear down) - Ruptured membranes - Decelerations in FHR are noted
42
Examination of Laboring Patient (Vaginal)
- Sterile gloves - Position to prevent supine hypotension - Drape to ensure privacy - Cleanse area if needed (perineum, vulva) - Permission from patient (insert index and middle finger) Determine - Dilation, effacement, position - Presenting part, position, station, molding of head - Status of membranes (intact, bulging, ruptured) - Amniotic Fluid (color, clarity, odor)
43
Amniotic Fluid Membrane and Fluid Assessment
- Occurs most commonly at active phase of 1st stage of labor - AROM (Artificial Rupture of Membranes) is called Amniotomy - Umbilical cord prolapse is a complication of membrane rupture (monitor FHR closely for a few minutes)
44
Infection
- Chorioamnionitis and Placentitis - Rupture of membranes allows microorganisms to ascend amniotic sac - Monitor maternal temperature every 2 hours to assess infection
45
Complications of Labor
- Intrauterine pressure >80mmHg or Resting Tone >20mmHg - Contraction lasing over 90 seconds - More than 5 contractions in 10 minutes - Relaxation between contractions longer than 30 seconds - Irregular FHR - Meconium stained fluid or blood from vagina - Maternal temperature over 100.4 - Foul smelling vaginal discharge - Persistent bright or dark red vaginal bleeding
46
Urinalysis
- Hydration status (specific gravity, color, amount) - Nutritional status (ketones) - Infection status (leukocytes) - Preeclampsia (proteinuria)
47
Blood Tests
- CBC to measure hematocrit, WBC, RBC, hemoglobin and platelets - Rapid HIV test for those who are undetermined "Type and Screen" or "Clot to Hold" determine blood type, rH, and antibodies - GBS can also be tested
48
Interventions for Anxiety
- Assess knowledge of labor - Teach expected progression and what to expect - Involve patient in decision making and share information of the progress of labor.
49
Acute Pain from frequency/intensity of Contractions
- Assess pain and teach coping methods - Teach non-pharmacological pain relief such as conscious relaxation, breathing, imagery and touch - Administer analgesics
50
Urinary Retention
- Patient should empty bladder every 2 hours (voiding or catheter) - Palpate bladder every 2 hours - Help patient to bathroom or catheterize - Teach voiding techniques such as listening to running water
51
Eliminiation
- Every 2 hours to avoid impeding descent of fetus and injuy
52
Ambulation
- Allow ambulation per orders if - Presenting part is engaged - Membranes are not ruptured (protect against prolapse) - Patient is not medicated (protects against injury)
53
Bed Rest
- Offer bedpan to prevent bladder distension - Encourage upright position on bedpan, allow tap water to run, place patients hand in warm water, pour warm water over vulva to encourage voiding - Privacy - Side rails up - Call bell and telephone within reach - Offer wash cloth for cleansing - Cleanse vulvar area - Catheterization if needed (insert in between contractions) (avoid force if there is resistance) - Rectal pressure from presenting part may cause sensation of bowel elimination - Help ambulation to bathroom if they do need to eliminate - Cleanse perineum after passage of stool
54
Ambulation/Position
- Upright position may be more pleasant. Associated with.. - Improved contraction intensity - Shorter labor - Reduced operative birth - Less pain medication needed - Increased maternal autonomy and control - Distraction - Allows close interaction with partner - Change position every 30-60 minutes - Side lying position is best
55
Semi-Recumbant
- Upper body elevated 30 degrees - Wedge under hip - The greater the angle the more gravity is exerted for fetal descent - Convenient for providing care and external fetal monitoring
56
Hands and Knees
- Knees and hands on bed - Relieves back ache - Facilitates Internal Rotation
57
Upright
- Gravity enhances contraction cycle - More oxytocin is secreted - (Ambulation or sitting up)
58
Lateral
- Alternate between left and right - Removes pressure from vena cava and back - Easier for back massage or counterpressure - Less frequent but more intense contractions - Difficult to get good quality fetal monitor tracings - Can be used as birthing position - Takes pressure off perineum - Reduced risk of perineal trauma - Facilitates internal rotation
59
Partner Support
- Orient partner to the labor room, cafeteria, waiting room, bathroom - Inform partner about sights and smells they may encounter - Respect their decision on how they would like to be involved - Tell them their presence is helpful - Offer to teach them comfort measures - Inform them on progress and patient needs - Prepare partner for changes in behavior and physical appearance of partner - Remind them to eat - Offer blankets and area to sleep - Eliminate unsettling stimuli such as extra lights, create calm environment
60
Doulas
- Professional labor support person | - Role is to provide physical and emotional support through encouragement, touching, stroking, and hugging.

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