6.1a First Stage of Labor Flashcards
First Stage of Labor
- 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
Assessment
- 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
True Labor
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
False Labor
- 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
Prenatal Data
- 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
Emergency Medical Treatment and Active Labor Act (EMTALA)
- 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)
Prenatal Factors to Tailor Care
- Age
- Height and Weight
- General Health Status
- Current Medical Conditions
- Allergies
- Respiratory Status
- Previous Surgical Procedures
Prenatal Records
- 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
Common Diagnostic and Fetal Assessments
- 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
Assessment
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
Interview
- 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
Triage
- Determine status of amniotic membrane
Sterile Speculum Examination and Nitrazine (pH)
- Cotton tip swab to test pH of fluid.
- Amniotic fluid is alkaline
- Urine/purulent material is acidic
Fern Test
- Determines if membranes have ruptured by getting a sample of cervical mucus smears
- When estrogen is elevated smears form a fern like pattern
Bloody Show
- Pink and sticky discharge
- Sign of labor
Brownish/bloody discharge may be caused by vaginal examination or coitus
MATERNAL TRIAGE CLASSIFICATIONS
STAT/Priority 1
- > 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
Urgent/Priority 2
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)
Prompt/Priority 3
- Temp >100.4, BP 140+/90+ asymptomatic
- Signs of active labor >34 weeks
- Early signs of labor
- Woman is not coping
Non-Urgent/Priority 4
- Common discomfort
- Vaginal discharge
- Constipation
- Ligament pain
- Nausea
- Anxiety
Scheduled/Priority 5
- Prescription refills
- Missed outpatient services
Postural Management (Position)
- Non-cephalic positions are risky (breech, transverse)
- Should be corrected before engagement but close enough to term where position will be maintained
External Cephalic Version (ECV)
- 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
Early Phase of Labor
- 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
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
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
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
Cultural Factors
- Encourage patients to request specific practices important to her
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
Physical Examination
- General Systems
- Fetal Status
- Uterine Contractions
- Vaginal Examination
- These serve as a baseline
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
Active Labor Examination
- BP, Pulse, RR, UA, FHR, Bloody show every 15 minutes
- Maternal appearance, mood, energy, involvement of partner every 5-15 minutes
General Systems Assessment
- Heart
- Lung
- Skin
- Edema in Face/Hands/Sacrum/Legs
- DTR
- Clonus (involuntary contractions)
- Weight
Vitals
- BP every 30 minutes if elevated between contractions
- Body temperature to identify infection or fluid deficit
Leopold Maneuvar
- Used to see fetal presentation/lie and fetal size
Fundus Assessment
- Head feels round, firm, freely moveable
- Breech is irregular and softer
- Identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech)
Abdominal Sides Assessment
- Identify where the fetal back and arms are
- This identifies fetal presentation (Left, Anterior, Cephalic)
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.
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)
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
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
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)
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)
Infection
- Chorioamnionitis and Placentitis
- Rupture of membranes allows microorganisms to ascend amniotic sac
- Monitor maternal temperature every 2 hours to assess infection
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
Urinalysis
- Hydration status (specific gravity, color, amount)
- Nutritional status (ketones)
- Infection status (leukocytes)
- Preeclampsia (proteinuria)
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
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.
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
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
Eliminiation
- Every 2 hours to avoid impeding descent of fetus and injuy
Ambulation
- Allow ambulation per orders if
- Presenting part is engaged
- Membranes are not ruptured (protect against prolapse)
- Patient is not medicated (protects against injury)
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
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
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
Hands and Knees
- Knees and hands on bed
- Relieves back ache
- Facilitates Internal Rotation
Upright
- Gravity enhances contraction cycle
- More oxytocin is secreted
- (Ambulation or sitting up)
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
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
Doulas
- Professional labor support person
- Role is to provide physical and emotional support through encouragement, touching, stroking, and hugging.