Chapter 12: The Process of Labor and Birth Flashcards
The 5 P’s of Labor
- Powers (physiological forces)- contractions
- Passageway (maternal pelvis)-birth canal
- Passenger (Fetus and Placenta)
- Passageway + Passenger and their relationship (engagement, attitude, position)
- Psychosocial influences (previous experiences, emotional status)
5 P’s: POWER
include the uterine contractions and the maternal pushing efforts
>Uterine muscular contractions
-primarily responsible for causing cervical effacement and dilation; also move the fetus down toward the birth canal during first stage of labor
-considered primary force of labor
>once the cervix is fully dilated, the maternal pushing efforts serve as an additional force
-during the second stage of labor, use of the maternal abdominal muscles for pushing (secondary force of labor) adds to the primary force to facilitate childbirth
Power: Uterine muscular contractions
primarily responsible for causing cervical effacement and dilation
- move the fetus down toward the birth canal during first stage of labor
- considered primary force of labor
Power: Maternal pushing efforts
once the cervix is fully dilated, the maternal pushing efforts serve as an additional force
-during the second stage of labor, use of the maternal abdominal muscles for pushing (secondary force of labor) adds to the primary force to facilitate childbirth
What are Contractions?
a rhythmic tightening of the uterus that occurs intermittently
-over time, the action shortens the individual uterine muscle fibers and aids in the process of cervical effacement and dilation, birth, and postpartal involution (reduction in uterine size after birth)
Contractions 3 distinct Components
- Increment (building of the contraction)
- Acme (peak of contraction)
- Decrement (decrease in the contraction)
What happens between Contractions?
uterus returns to a state of complete relaxation
- this rest period allows the uterine muscles to relax and provides the woman with a short recovery period that helps her to avoid exhaustion
- uterine relaxation between contractions is important for fetal oxygenation because it allows for blood flow from the uterus to the placenta to be restored
Why is Uterine Relaxation between contractions important for fetal oxygenation?
it allows for blood flow from the uterus to the placenta to be restored
Changes to the Uterine Muscular because of Contractions
- upper portion of the uterus becomes thicker and more active
- the lower uterine segment becomes thin-walled and passive
- the boundary between the upper and lower uterine segments becomes marked by a ridge on the inner uterine surface (“physiological retraction ring”)
- the uterus elongates with each contraction
Because of Contractions, the uterus elongates. What does Elongation do?
elongation causes a straightening of the fetal body so that the upper body is pressed against the fundus and the lower, presenting part is pushed toward the lower uterine segment and the cervix
-Fetal axis pressure= the pressure exerted by the fetus
>as the uterus elongates, the longitudinal muscle fibers are stretched upward over the presenting part
-this force, along with the hydrostatic pressure of the fetal membranes, causes the cervix to dilate (open)
Fetal Axis Pressure
pressure exerted by the fetus
How are Contractions Described?
frequency, duration, and intensity
How is Frequency of a Contraction Determined?
measured from the beginning of one contraction to the beginning to the next contraction
How is Duration of a Contraction Determined?
measured from the start of one contraction to the end of the same contraction
How is Intensity of a Contraction Determined?
measured by uterine palpation and is described in terms of mild, moderate, and strong
How to Palpate Contractions
noninvasive procedure
- place the fingertips of one hand on the fundus of the uterus (where most contractions can be felt)
- apply gentle pressure and keep hand in the same place (moving the hand over the uterus may stimulate additional contractions)
How to Determine The Firmness of the Uterus
Uterine fundus can determine the firmness of the uterus and whether there is an ability to indent the uterus at the acme (peak) of the contraction
-Palpating the intensity is often compared with palpating ones nose (mild intensity), chin (moderate intensity), or forehead (strong intensity)
Descriptions of Intensity for Contractions
- When uterine fundus remains soft at the acme (peak) of a contraction= “mild”
- Inability to indent the uterus at acme of a contraction= “strong”
- In between; firm fundus that is difficult to indent with the fingertips= moderate
Tocodynamometer
pressure sensitive device that is applied against the uterine fundus
-external contraction monitoring device
>when the uterus contracts, the pressure that is exerted against the “toco” is measured and recorded on graph paper
Contractions Intensity is best assed with what method?
palpation
External Electronic Monitoring
- continuous or intermittent
- provides information about the frequency and duration of contractions
- may not give accurate data regarding the intensity of contractions because of variables (e.g. maternal position, obesity, and the placement of the monitor on the uterus)
- Tocodynamometer
Internal Monitoring
-measures intensity of uterine contractions
-invasive
>if the amniotic membranes have ruptured, an internal pressure catheter is inserted through the cervix and into the uterus to measure the internal pressure generated during the contraction
Normal resting pressure (resting tone) in the uterus (between contractions)
10 to 12 mm Hg
During Acme, what is the contractions intensity range for early labor?
25 to 40 mm Hg
Intensity Contraction Range during Active Labor?
50 to 70 mm Hg
Intensity Contraction Range during Transition stage of labor?
70 to 90 mm Hg
What is the Intensity Contraction Range During Maternal Pushing in the Second Stage of Labor?
70 to 100 mm Hg
Early Labor Contraction Characteristics
- weak and irregular
- last 30 seconds
- occur every 5 to 7 minutes
- as pattern becomes known, they become regular in frequency, longer in duration, and increased in intensity
Effacement
process of shortening and thinning of the cervix
- as contractions occur, the cervix becomes shorter until the cervical canal disappears
- amount of effacement is expressed as a percentage related to the length of the cervical canal
ex: if a cervix has thinned to half the normal length of a cervix, it is 50 % effaced
Dilation
opening and enlargement of the cervix that progressively occurs throughout the first stage of labor
- expressed in centimeters (cm)
- full dilation= 10 cm
- with continued uterine contractions, the cervix eventually opens large enough to allow the fetal head to come through
How is Effacement and Dilation Evaluated?
by a vaginal examination performed by a qualified practitioner (e.g. maternity nurse who has received specialized training in this procedure)
-the vaginal exam provides info regarding diameter of the opening of the cervix (ranges from 1 cm to 10 cm), the status of the amniotic membranes (ruptured or intact), and the fetal presentation and the station, or the extent of the fetal descent through the maternal pelvis
>once the cervix is fully dilated and retracted up into the lower uterine segment, it can no longer be palpated
Maternal Pushing Efforts
after the cervix has become fully dilated, the laboring woman usually experiences involuntary “bearing down” sensation that assists with expulsion of the fetus
-at this time, the woman can use her abdominal muscles to aid in the expulsion
Why must the cervix be fully dilated before the patient is encouraged to push?
bearing down on a partially dilated cervix can cause cervical edema and damage and adversely affect the progress of labor
-the urge to bear down occurs when the fetal head reaches the pelvic floor
5 P’s: Passageway
consists of the maternal pelvis and the soft tissues
-the bony pelvis that the fetus must pass through is divided into 3 sections: inlet, mid-pelvis (pelvic cavity), and outlet
>each of these sections has a unique shape and dimension that the fetus must maneuver to be born vaginally
Four Classic Pelvis Types
- gynecoid
- android
- platypelloid
- anthropoid
5 P’s: Passenger
comprises the fetus and the fetal membranes
-fetus presents in a head-first position
Fetal Skull
-least flexible part of the fetus
-largest body structure
-because of sutures and fontanelles, there is some flexibility; allow the cranial bones the capability of movement and they overlap in response to the powers of labor
>Molding= the overlapping or overriding of the cranial bones
-consists of 3 components: the face, base of the skull, and the vault of the cranium (roof)
Fetal Lie
refers to the relationship of the long axis of the woman to the long axis of the fetus
- Longitudinal lie
- Transverse lie
- Oblique lie
Fetal Lie: Longitudinal lie
the head to tailbone axis of the fetus is the same as the woman’s
-either the fetal head or the fetal buttocks enter the pelvis first
Fetal Lie: Transverse lie
the head to tailbone axis of the fetus is at a 90-degree angle to the woman
Fetal Lie: Oblique lie
is one that is at some angle between the longitudinal an the transverse lie
Landmarks of the Fetal Skull
- Mentum: fetal chin
- Sinciput: anterior area known as the “brow”
- Bregma: large, diamond-shaped anterior fontanelle
- Vertex: area between the anterior and posterior fontanelle
- Posterior Fontanelle: the intersection between the posterior cranial sutures
- Occiput: the area of the fetal skull that is occupied by the occipital bone, beneath the posterior fontanelle
Fetal Attitude
describes the relationship of the fetus body parts to one another
-normal= attitude of flexion; “fetal position”
>can be flexion (vertex), moderate flexion (military), or extension
Fetal Attitude: Flexion (vertex)
-the fetal head is flexed, so that the chin touches the chest
-the arms are flexed and folded across the chest
-the thighs are flexed on the abdomen
-calves are flexed against the posterior aspect of the thighs
“fetal position”
Fetal Attitude: Moderate Flexion
-the fetal chin is not touching the chest but is in an alert, or “military position”
>this position causes the occipital frontal diameter to present to the birth canal
-does not interfere with labor
Fetal Attitude: Extension
presents the brow or face of the head to the birth canal
Preferred Fetal Attitude for Birth
flexion of the fetal head (which the chin touches the chest) because it allows the smallest anteroposterior diameter of the fetal skull to enter into the maternal pelvis
-any other position will present with a larger anteroposterior diameter, which contributes to a longer more difficult labor
Fetal Presentation
fetal part that enters the pelvic inlet first ad leads through the birth canal during labor
-may be cephalic, breech, or shoulder
Presenting Part
the part of the fetal body first felt by the examining finger during a vaginal examination
-is determined by the fetal lie and attitude
Fetal Presentation: Cephalic
identifies that the fetal head will be first to come in contact with the maternal cervix
-most desirable position
Advantages of the Cephalic Presentation
- fetal head is usually the largest part of the infant; once the fetal head is born, the rest of the body usually delivers without complications
- fetal head is capable of molding; there is sufficient time during labor and descent for molding of the fetal head to occur; molding helps the fetus to maneuver through the maternal birth passage
- fetal head is smooth and round, which is the optimal shape to apply pressure to the cervix and aid in dilation
4 Types of Cephalic Presentation
- Vertex
- Military
- Brow
- Face
Cephalic Presentation: Vertex
fetal head presents fully flexed
- most frequent and optimal presentation because it allows the smallest suboccipitalbregmatic diameter to present
- “vertex presentation”
Cephalic Presentation: Military
fetal head presents in a neutral position, which is neither flexed nor extended
-top of the head is the presenting part
Cephalic Presentation: Brow
fetal head is partly extended
- an unstable presentation that converts to a vertex if the head flexes or to a face presentation if the head extends
- the sinciput (fore and upper part of the cranium) is the presenting part
Cephalic Presentation: Face
fetal head is fully extended and the occiput is near the fetal spine
-face is the presenting part
Fetal Presentation: Breech
occurs when the fetal buttocks enter the maternal pelvis first
- likely occur in preterm births or in the presence of a fetal abnormality such as hydrocephaly (head enlargement caused by fluid) that prevents the head from entering the pelvis
- a C-section is usually indicated
Disadvantages Associated with A Breech Presentation
- increased risk for umbilical cord prolapse because presenting part may not be covering the cervix (e.g. footling breech)
- the presenting part (buttocks or feet) is not as smooth and hard as the fetal head and is less effective in dilating the cervix
- once the fetal body (abdomen) is delivered, the umbilical cord can become compressed; the fetus must then be delivered expeditiously to prevent hypoxia; rapid delivery may be difficult because the fetal head is usually the largest body part, and in this situation, there is no time to allow for molding
3 Different Types of Breech Presentations
- Frank
- Complete (Full)
- Footling
Breech Presentation: Frank
- most common of all breech presentations
- the fetal legs are completely extended up toward the fetal shoulders; the hips are flexed, the knees are extended, and the fetal buttocks present first in the maternal pelvis
Breech Presentation: Complete (Full)
same as the flexed position with the fetal buttocks presenting first
- legs are typically flexed
- reversal of the common cephalic presentation
Breech Presentation: Footling
one or both of the fetal legs are extended with one foot (“single footling”) or both feet (“double footling”) presenting first into the maternal pelvis
Shoulder Presentation
a transverse lie
- rare
- when a transverse lie is present, the maternal abdomen appears large from side to side, rather than up and down
- woman may also demonstrate a lower than expected (for gestational age) fundal height measurement
- shoulder usually presenting part; but fetal arm, back, abdomen, or side may present
- occurs with preterm birth, high parity, prematurely ruptured membranes, hydramnios, and placenta previa
- require C-section
Passageway + Passenger
relationship between the passageway (maternal pelvis) and the passenger (fetus and membranes)
Engagement
occurred when the widest diameter of the fetal presenting part has passed through the pelvic inlet
- determined by external palpation or vaginal examination
- occurred when the presenting part reaches stage 0
Station
the level of the presenting part in relation to the maternal ischial spines
-lies above maternal ischial spines= minus station
-lies below maternal ischial spines= positive station
>if the station does not change in the presence of strong, regular contractions, this may indicate a problem with the relationship between the maternal pelvis and the fetus (cephalopelvic disproportion)
Position
location of a fixed reference point on the fetal presenting part in relation to a specific quadrant of the maternal pelvis
-can be right anterior, left anterior, right posterior, and left posterior
-four quadrants designate whether the presenting part is directed toward the front, back, right, or left of the passageway
>Right (R) or Left (L) side of the maternal pelvis
>The Landmark of the presenting part: occiput (O), mentum (M), sacrum (S), or acromion process (A)
>Anterior (A), Posterior (P), Transverse (T): depends on whether the landmark is in the front, back, or side of maternal pelvis
ex: Right occiput anterior (ROA), Right Occiput Transverse (ROT), Right Occiput Posterior (ROP), Right Mentum Posterior (RMP)
>first and last letter refer to maternal pelvis
>middle letter refers to the presenting part of the fetus
occiput
somewhere on top of the head
Mentum
chin
Assessing Cultural influences of the laboring patient: to provide culturally sensitive care to the laboring patient, the nurse should consider..?
- the patient’s and families level of comfort with the nurses “language” and whether an interpreter is needed
- who is the designated birth support person and what will be the extent of the person’s role
- the patient’s level of comfort with touch
- if any special rituals or practices will be used during the childbirth experience
Fetal position most common and most favorable for birth?
right occiput anterior (ROA)
Why is it important for the nurse to identify the position of the fetus?
identify if the fetus is in an optimal position for a vaginal birth
- ROA optimal
- uses inspection and palpation of the maternal abdomen and vaginal examination
Contractions: Frequency
from beginning of one contraction to beginning to the next contraction
Contractions: Duration
time between start to end of one contraction
Contraction: Intensity
strength of contraction at the peak
Signs and Symptoms of Impending Labor
- Lightening
- Braxton Hicks Contractions
- Cervical Changes
- Bloody
- Rupture of the Membranes
- Energy Spurt
- Weight loss
- Gastrointestinal Disturbances
S/S of Impending Labor: Lightening
-marks the beginning of engagement
-usually at about 38 weeks in primigravid pregnancy
-the presenting part (usually fetal head), settles downward into the pelvic cavity, causing the uterus to move downward as well
-as the uterus moves downward, the woman may state her baby has “dropped”
-may report changes in the appearance of her abdomen; flattening of the upper area and an enhanced protrusion of the lower area
>this downward settling of the uterus may decrease the upward pressure on the diaphragm= easier breathing
-downward settling may lead to: leg cramps or pains, increased pelvic pressure, increased urinary frequency, increased venous stasis causing edema in the lower extremities, increased vaginal secretions because of congestion in the vaginal mucosa
S/S of Lightening
-state her baby has “dropped”
-changes in appearance of abdomen; flattening of the upper area and an enhanced protrusion of the lower area
-easier breathing
-the downward settling may lead to:
>leg craps or pains, increased pelvic pressure, increased urinary frequency, increased venous stasis causing edema in the lower extremities, increased vaginal excretions because of congestion in the vaginal mucosa
S/S of Impending Labor: Braxton Hicks Contractions
-approaching term
-irregular contractions
-can occur every 10 to 20 minutes
-felt in abdomen or groin area
-may mistake them for true labor
-associated with increased discomfort
-“false labor”
>contractions contribute to the preparation of the cervix and uterus for the advent of true labor; these do not lead to dilation or effacement of the cervix
S/S of Impending Labor: Cervical Changes
- nonpregnant woman cervix = rigid
- for preparation for passage of fetus the cervix softens (cervical ripening), stretches, and thins and is taken up into the lower segment of the uterus
- Softening and thinning= effacement
S/S of Impending Labor: Bloody Show
blood-tinged mucus plug
-presence indicates labor will begin within 24 to 48 hours
-during pregnancy the cervix is plugged with mucus; the mucus plug acts as a protective barrier for the uterus and its contents through pregnancy
>as the cervix begins to soften, stretch, and thin through effacement, there may be rupture of small cervical capillaries; the added pressure created by engagement of the presenting part may lead to the expulsion of a blood tinged mucus plug (bloody show)
S/S of Impending Labor: Rupture of the Membranes
spontaneous rupture of the amniotic sac (“ruptured membranes” or “ruptured bag of waters”) prior to the onset of labor
>assessment by the woman if rupture occurs at home, or by the nurse if it occurs at the birthing unit is essential
What if rupture of the membranes happens at home?
have the patient immediately contact the nurse at the providers office or at the birthing center who will advise her to report for an examination
How to Assess the amniotic fluid once the membranes have ruptured
-note the color, amount, and odor
>should be clear and odorless; can contain white specks (vernix caseosa) and fetal hair (lanugo)
>yellow-green tinged amniotic fluid may indicate infection or fetal passage of meconium
>presence of amniotic fluid can be confirmed by a Nitrazine tape test, an AmniSure test, or by a fern test because amniotic fluid might be mistaken as urine
What does yellow-green tinged amniotic fluid inidcate?
infection or fetal passage of meconium which signals the need for further assessment and fetal heart rate monitoring
What test are used to determine if amniotic fluid is present
-Nitrazine tape test, AmniSure test, or a fern test
>Urinary incontinence (frequently associated with urgency, coughing, and sneezing) is sometimes confused with ruptured membranes
S/S of Impending Labor: Energy Spurt
“nesting”
- toward end of pregnancy, experience a sudden increase in energy coupled with a desire to complete household preparations for the new baby
- may be related to an increase in adrenaline, which is needed to support woman during the work of labor
- do not overexert themselves doing household chores, save energy for childbirth
S/S of Impending Labor: Weight Loss
changes in levels of estrogen and progesterone= electrolyte shifts and may result in the reduction of fluid retention
-can be up to 3 pounds
S/S of impending Labor: GI Disturbances
diarrhea, nausea, vomiting, or indigestion
True Labor
- lead to progressive dilation and effacement of cervix
- contractions occur regularly and increase in frequency. duration, and intensity
- pain begins in lower back region and radiates to the abdomen
- pain intensifies with activity such as walking
False Labor
- irregular contractions
- no increase in frequency, duration, and intensity of contractions
- pain occurs in abdominal region
- no change in the cervix
- walking may lessen the pain
Questions to ask the patient who calls the birth unit to see if she should come in or stay home
- What is your due date?
- are your membranes ruptures? or Did your water break?, and are you having any bleeding or vaginal discharge?
- describe your contractions: When did they start? How frequent? How long? How strong?
- is the fetus active?
- what helps with the discomfort?
- who is with you?
When to report to the birthing center: guidelines for admission
- Primigravida: contractions are regular, occur about every 5 minutes for at least 1 hour
- Multipara: contraction are regular, occur about every 10 minutes for at least 1 hour
- any gush of fluid needs to be evaluated, even if there are no contractions
- the mucus plug or “bloody show” is usually pink or dark red. Any bright red bleeding requires immediate evaluation
- any decrease in fetal movement
- any cause for worry or anxiety in the pregnant woman needs to be explored by the nurse and may lead to admission
EMTALA regulations
-provide services to pregnant women when an urgent pregnancy problem such a labor, rupture of the membranes, decreased fetal movement, or recent trauma is experienced
-fully document all relevant information to include assessment findings, interventions implemented, and the patient’s response to the care provided
>any pregnant woman who presents to an obstetric triage is considered to be experiencing “true labor” until qualified health-care provider determines she is not
The Focused Assessment
to determine the condition of the mother and fetus and the progression of labor
- assess fetal well being by recording fetal heart rate (FHR) and noting the FHR response to uterine contractions (contractions quantified in a 10 minute window, averaged over 30 minutes)
- notes duration, intensity, and relaxation time between contractions
- assess fetal movement
- membranes ruptured= nurse validates presence of amniotic fluid and examines fluid for color and odor
- baseline vital signs
- assess progression of labor by monitoring pattern of uterine contractions for frequency, duration, and intensity
- assess labor status by evaluating cervical dilation, effacement and fetal station, presentation, and position
The Cultural Assessment
- assess cultural preferences, practices and values related to labor and childbirth
- care provider gender preference, comfort level with intimate touch, and the presence or absence of a labor support person
- woman’s responses to labor pain, her acceptance or rejection of labor support interventions, and her emotional responses to the newborn can be culturally based
Psychosocial Assessment
-understanding behavioral responses to the pregnancy and childbirth experience= support and identify coping mechanisms
-info about family and support systems
-living conditions
-family violence; interview alone
-drug use
-alcohol abuse
>ask questions more openly such as “how many drinks do you have each day” , instead of “do you drink alcohol”= closed responses such as yes and no
Initial Admission Labortory Tests
- test for blood type and Rh factor
- complete blood count (CBC)
- hemoglobin and hematocrit
- blood glucose
- syphilis, Hepatitis B, and HIV also collected
- Urine specimen for presence of protein, glucose, and ketones
Documentation of Admission
- documentation forms provided
- collecting a complete health and childbirth history and performing a physical exam of patient and fetus provide essential foundation
- uses birth settings recording procedures
- notifies the patients primary care provider of the admission status
Critical Information to relay to the physician or nurse-midwife
- patients name and age
- gravidity and parity
- gestational age and estimated date of delivery
- labor status: pattern of contractions, cervical dilation and effacement, fetal presentation and station
- status of membranes
- FHR and response to contractions
- vital signs, (BP and temp)
- identified risk to maternal or fetal ell being
- patients coping ability in response to labor
First Stage of Labor
stage of dilation
- latent, active, transitional phase
- begins with the onset of regular uterine contractions and ends with complete dilation of the cervix (10 cm)
- most often longest stage
- over time, contractions increase in frequency. duration, and intensity
First Stage of Labor: Latent Phase
begins with establishment of regular contractions (labor pains)
- contractions about 5 minutes apart, last 30-45 seconds, and mild
- cervical effacement and early dilation (0-3 cm)
- last as long as 10-14 hours because contractions are mild and cervical changes are slow
- contractions begin as painful menstrual-like cramps or low backache
- this phase often occurs at home; pain often well controlled, various behaviors like excited, talkative, confident, anxious, withdrawn
First Stage of Labor: Active Phase
more active contractions
- contractions every 3 to 5 minutes, lasting loner (60 seconds) and are moderate to strong intensity
- cervical dilation 4-7 cm
- increasing discomfort as contractions become stronger and more regular; may have backache
- patients focus more on staying in control and managing the pain; often requires coaching; quieter and more inwardly focused
First Stage of Labor: Transitinal stage
most intense phase
- frequent strong contractions that occur 2 to 3 minutes apart and last 60 to 90 seconds
- 8-10 cm dilated
- increasing discomfort because contractions are very strong with little time for relaxation in between; as the fetal head descends there may be an increase in rectal pressure and the urge to push
- often difficult to cope; irritable, agitation, hopeless, tired
During Labor, how long does the cervix take to dilate?
- Nulliparous= usually 1 cm/hr
- multiparas= 1.5 cm/hr
Friedman Curve
assessment tool; graph used to help identify whether a patients labor is progressing in a normal pattern
-contains time of day, amount of cervical dilation and effacement, and hours of labor that have been elapsed
Labor Support
- presence of nurse
- spirituality
- promotion of comfort
- anticipatory guidance
- caring for birth partner
- ensuring culture-centered care
Promotion of comfort
- position changes
- personal comfort measures
Various Positions for Labor
- walking/standing
- sitting
- hands and knees position
- squatting
Advantages and Disadvantages to walking/standing
- Advantage: uses gravity, facilitates descent, places fetus in alignment with pelvis, may decrease length of labor by enhancing the effect of contractions; encouraged to remain ambulatory to enhance normal progression of labor
- Disadvantage: may be tiring, requires telemetry for continuous electronic fetal monitoring, may not be possible with anesthesia
Advantages and Disadvantages of Sitting
- Advantages: uses gravity, increases pelvic diameter and shortens second-stage labor, avoids supine hypotension syndrome, decreases back pain, enhances communication with partner and allows for ready access to back and sacrum for massage and counter-pressure
- Disadvantage: labor may be slowed if not alternated with other positions, may intensify suprapubic pain and cause edema of vulva or cervix
Advantages and Disadvantages of Hands and Knees Position
- Advantages: stimulates rotation of fetus from a posterior to anterior position, relieves backache and rectal pressure, facilitates pelvic rocking and pelvic mobility
- Disadvantages: may be tiring or embarrassing, difficult to keep external monitor in place, may not be possible with regional anesthesia
Advantages and Disadvantages of Squatting
- Advantages: uses gravity, increases pelvic diameter, relieves backache, promotes fetal descent and rotation, facilitates second stage pushing
- Disadvantages: may impede descent before engagement has occurred, may be tiring, uncomfortable, or embarrassing, may increase perineal and cervical edema
Personal Comfort Measures
- environment
- personal hygiene
- elimination (q 2 hrs)
- relaxation techniques (visualization, focal points, imagery, hydrotherapy, breathing techniques)
- items from home to enhance relaxation; music, picture, or stuffed animal
Anticipatory guidance
- helpful information can be guided in general terms
- factual feedback and positive reinforcement of the progress made
- encouragement
- keeping family and patient informed about the progress of labor and birth is a constant and ever-changing task
Caring for Birthing Partner
- help support person feel welcomed
- orientation to birth unit
- identify where to locate items such as towels, washcloths, kitchen supplies (ice chips), and restroom
- assess the degree of involvement of support person
Different Ways to identify Fetal position
- abdominal palpation (Leopold maneuvers)
- location of the point of auscultation of the fetal heart rate (FHR)
- vaginal examination
- ultrasound
Electronic Fetal Heart Rate Monitor (external)
- intermittent or continuous
- Continuous for: hx of stillbirth (in utero fetal death at greater than or equal to 38 weeks), presence of a complication in pregnancy (preeclampsia-eclampsia, placenta previa, abruptio placentae, multiple gestation, and prolonged or premature rupture of membranes), induction of labor with oxytocin, when IA identifies a need for more detailed information about FHR, or if institution unable to provide IA.
- composed of a doppler ultrasound transducer and tocodynanometer that is applied to the maternal abdomen to monitor and display the FHR and contractions
Internal Fetal Monitor
composed of spiral electrode that must be inserted into the fetal scalp or presenting part during a vaginal examination
-the cardiac signal is transmitted through the spiral electrode and a fetal electrocardiogram tracing is produced
>uterine activity is assessed by a solid or fluid-filled intrauterine pressure catheter (IUPC) that is introduced into the uterine cavity; IUCP can measure contractions frequency, duration, and intensity
>reserved for high-risk pregnancies
-application of internal electrode requires the membranes be ruptured and cervix has sufficiently dilated
Baseline fetal heart rate
-110-160 bpm
>tachycardia= >160 bpm
>bradycardia= <110 bpm
(in a duration of 10 minutes or longer)
Conditions associated with fetal tachycardia
> 160 bpm
- Fetal hypoxia: the fetus attempts to compensate for reduced blood flow by increasing sympathetic stimulation of the CNS
- Maternal fever: an increase in maternal temperature accelerates fetal metabolism, thus increasing FHR; this situation may be seen in laboring woman who become dehydrated or has an increased temperature following prolonged exposure in warm bath or whirlpool
- Maternal medications: parasympathetic drugs (atropine and scopolamine) and beta-sympathetic drugs (tocolytic drugs used to halt contractions) can have a stimulant effect and increase FHR)
- Infections
- Fetal Anemia
- Maternal hyperthyroidism
Conditions associated with fetal bradycardia
<110 bpm
- late fetal hypoxia
- medications
- maternal hypotension: decreased blood flow to the fetus
- maternal or fetal hypothermia nd dehydration
- prolonged umbilical cord compression
- fetal bradyarrhythmia’s
- uterine tachysystole
- abruptio placentae
- uterine rupture or vasa previa
- vagal stimulation during the second stage
- chronic fetal head compression
Interventions for Fetal Bradycardia
-confirm the EFM is monitoring the FHR rather than the maternal HR, then assess for fetal movement and the fetal response to fetal scalp stimulation (performed when the FHR is between contractions)
-vaginal exam to assess for umbilical cord prolapse
-assessment of maternal vital signs and hydration status with prn fluid administration may be useful in reducing contractions and in promoting fetal oxygenation
>depending on other parameters (ex FHR variability): discontinuing oxytocin, administering oxygen (8-10 L/min by mask), modifying pushing pattern, and notifying primary care provider
Baseline Variability of FHR
manifested by fluctuations in the baseline fetal heart rate observed on the fetal monitor
-indicative of an adequately oxygenated neurological pathway in which impulses are transmitted from the fetal brain to the cardiac conduction system
-the pattern denotes an irregular, changing FHR rather than a straight line that indicates few changes in rate
>most important predictor of fetal oxygenation
-absent, minimal, moderate, or marked
FHR Variability: Absent
- Amplitude= undetectable
- may represent fetal cerebral asphyxia (deprived of oxygen)
- warrants immediate evaluation
FHR Variability: Minimal
> 2 -<5 beats/min
-may be related to narcotics, tranquilizers, magnesium sulfate, barbiturates, anesthetic agents, supine hypotension, cord compression, uterine tachysystole, prematurity, or fetal sleep
FHR Variability: Moderate
6-25 bpm
-indicative of fetal well-being
FHR Variability: Marked
> 25 bpm
-less common response to fetal hypoxia
Critical Nursing Action: When Minimal or Absent Variability is Detected
minimal or absent variability that does not appear to be associated with a fetal sleep cycle or the administration of maternal medications may signal fetal hypoxia or acidosis
-nursing actions when detected:
>assist the patient into a position that promotes enhanced fetal oxygenation
>assess the fetal response to fetal scalp stimulation or vibroacoustic stimulation
>assess maternal hydration; administer an IV bolus to reduce uterine activity and promote increased uterine perfusion
>discontinue oxytocin to reduce uterine activity
>administer oxygen (8-10 L/min by mask) to promote fetal oxygenation
>consider more invasive monitoring (internal fetal scalp electrode)
>offer support to the patient and birth partner
>notify primary care provider
Periodic changes
accelerations and decelerations in the FHR that occur in relation to uterine contractions and persist over time
>early, variable, late, and prolonged
Episodic changes
FHR acceleration and deceleration patterns that are not associated with uterine contractions
Accelerations
increase in the fetal heart rate of 15 bpm above FHR baseline that last for at least 15 seconds to less than 2 minutes
- sign of fetal well-being when accompany fetal movement
- when contractions are present, accelerations are often noted as a response to the contraction
- may occur before, during, or after contractions
Decelerations
any decrease in FHR below the baseline FHR
-classified according to their shape, timing, and duration to uterine contractions
>early, variable, late, prolonged
Early Decelarations
-visually apparent
-usually symmetrical
-gradual decrease and return of the FHR associated with a uterine contraction
-onset of the deceleration begins near the onset of the contraction, lowest part of the deceleration occurs at the peak of the contraction, and the FHR return to baseline by the end of the contraction
-repetitive
-observed during active labor and descent of the fetus
-considered benign, well tolerated by fetus
-indicator of fetal well-being and adequate oxygen reserve
>head is engaging into pelvis and we expect that at delivery
Variable Decelerations
variable in terms of onset, frequency, duration, and intensity
- below baseline 15 bpm or more, last for 15 seconds, and returns to baseline in less than 2 minutes from time of onset
- appear in the shape a s a “U”, “W”, or “V”
- occur at any time during uterine contracting phase
- may be because of umbilical cord prolapse, or something to do with the cord
- vary moms position
“normal” variable decelerations
- less than 60 seconds
- rapid return to the baseline, and accompanied by a normal baseline and variability
“abnormal” variable decelerations
- slow return to baseline
- persistence to less than 60 bpm
- greater than 60 seconds
- presence of overshoots, tachycardia, and repetitive overshoots and absent variability
Variable decelerations: “Shouldering”
compensatory response to hypoxemia
- variable deceleration is proceeded by brief acceleration of FHR
- increase in the FHR of 20 bpm for less than 20 seconds
Variable deceleration: Over shoot/ rebound overshoot
gradual smooth acceleration after deceleration of 10 to 20 bpm for more than 60 seconds to 90 seconds
Late Decelerations
-visually apparent
-gradual decrease in and return to baseline FHR associated with uterine contraction
-has late onset and begins around the peak of the contraction
-does not resolve until the contraction has ended
-indicates presence of uteroplacental insufficiency (decline in placental function)
-require prompt attention and reporting
-presence of persistent and repetitive late decelerations is indicative of fetal hypoxemia that may progress to hypoxia and metabolic acidemia
>heart rate drops after contraction; placenta isn’t working (tear, hemorrhage, placenta previa)
>left side, 02
VEAL CHOP VEAL
Variable Cord Vary
position
Early Head Expected at
Delivery
Accelerated OKAY Assure mom
Late Placental
Insufficiency Left side, O2
Second Stage of Labor
delivery of the fetus
- begins with full dilation (10 cm) of the cervix and ends with the expulsion (birth) of the fetus
- contractions 2-3 minutes apart, lasting 60 seconds, and strong by palpation
- may have a strong urge to push
- prefer to push so that they can use the contractions to work with them
- when head is crowning, may feel intense pain, burning
- many get a “second wind” as they see they are making progress
Closed-glottis pushing
“directed pushing”
- woman begins pushing at full cervical dilation regardless of urge to bear down
- avoid holding breath and bear down as in a Valsalva maneuver while pushing as hard as she can through the maneuver= leads to prolonged labor, and adverse fetal effects
Open-glottis pushing
“involuntary pushing”
- recommended
- air is released during pushing so that no intrathoracic pressure builds up
- encouraged to hold breath for only 5 to 6 seconds during pushing and take several breaths between each bearing down effort
- allowed to exhale throughout bearing down attempts
Crowning
birth is imminent, occurs when the fetal head is encircled by the vaginal introitus
Degree of Lacerations
may occur in cervix, vagina, and perineum
-immediately after birth the cervix, vagina, and perineum are inspected to assess for tissue damage
>First degree: involve the perineal skin, and vagina mucous membrane
>Second degree: involve the skin, mucous membrane, and fascia of the perineal body
>Third degree: involve the skin, mucous membrane, and muscle of the perineal body and extend to the rectal sphincter
>Fourth Degree: extend to the rectal mucosa and expose the lumen of the rectum
Episiotomy
surgical incision of the perineum that is performed to enlarge the vaginal orifice during the second stage of labor
>Midline: made from vaginal opening downward toward the rectum
>Mediolateral: made from the vagina to the 5 or 7 o’clock position
The Cardinal Movements
mechanisms of labor
-to describe how the fetus passes through the birth canal and the positional changes required to facilitate birth
-cardinal movements are presented as they occur:
>descent, flexion, internal rotation, extension, restitution, external rotation, expulsion
Appreciating Benefits of Delayed Cord Clamping
- provides more blood volume, red blood cells, and hematopoietic stem cells to the neonate than when the cord is cut immediately
- placental circulation continues for a few moments after birth, supplying the neonate with oxygen
- the oxygen-rich blood flowing through the umbilical cord allows the neonate additional protected time to adjust to the outside world and a new way of breathing
The nurse observes the cut cord for the presence of what?
- two arteries and one vein
- samples of cord blood are collected for laboratory analysis
Nursing Diagnoses for the Intrapartal Patient
- Pain r/t increasing frequency, duration, and intensity in contractions
- knowledge deficit r/t pain management techniques for active labor
- anxiety r/t the previous birth experience
- fatigue r/t a prolonged latent phase labor
- risk for infection r/t prolonged rupture of membranes
- impaired fetal gas exchange r/t umbilical cord compression
- decreased maternal cardiac output related to supine hypotension secondary to maternal position
Third Stage of Labor
begins with the birth of the infant and ends with the delivery of the placenta
- takes 5-10 minutes, or up to 30 minutes
- uterus should be firmly contracted
- uterus rises upward
- umbilical cord descends further through the vagina
- gush of blood as placenta detaches
- some discomfort or cramping as the placenta is expelled
- Maternal behaviors: focus on infant well-being, crying common, expressions of relief, culturally influenced
Fourth Stage of Labor
time of physiological adaptation that begins following delivery of the placenta
- lasts 1-2 hours
- uterus firmly contracted
- lochia rubra, bright red blood flow with occasional small clots
- vital signs return to prelabor values
- may experience perineal discomfort usually r/t trauma from episiotomy or tearing, or hemorrhoids
- maternal behaviors: excited, tired, bonding and attachment with infant, initiation of breast feeding, culturally influenced
Nursing Care of the Mother During Third Stage Of Labor
-observe for signs that placenta has separated from uterine wall
-uterus is palpated to determine the rise upward and characteristic change in shape from resembling a disk to globe
-oxytocic medications such as Pitocin and Syntocinon are administered at the time of delivery of the placenta; used to stimulate uterine contractions, thereby minimizing the bleeding from the placental attachment site and reducing the risk of postpartum hemorrhage
>other meds such as methylergonovine maleate (Methergine) or carboprost tromethamine (Hemabate) may be given IM to control blood loss
-assess volume of blood loss
-monitor vital signs (BP and HR)
-inspect placenta, make sure all cotyledons are intact; report any missing fragments; must be removed can cause hemorrhage and infection
Immediate Nursing Care of the Newborn
- initiation of newborns respirations
- drying newborn and initiate suctioning
- provide adequate stimulation to initiate respiratory effort
- modified Trendelenburg position of newborn
- prevent heat loss; place on mother abdomen; dries infant, discards wet linens, applies warm blankets
- skin-skin contact
Apgar Scoring System
-done at 1 minute and again at 5 minutes
>Heart rate, Respiratory effort, Muscle Tone, Reflex Irritability, and Color
Apgar Scoring System: Heart Rate
-priority
-absent or less than 100 bpm= resuscitation
Apgar Scoring:
0= Absent
1= slow; below 100
2= Above 100
Apgar Scoring: Respiratory Effort
vigorous cry best indicates respiratory effort -weak or absent cry= intervention Apgar Scoring: 0= Absent 1= slow; irregular, weak cry 2= good; strong cry
Apgar Scorning: Muscle Tone
assess response to extension of extremities Apgar Score: 0= flaccid 1= some flexion of extremities 2= well flexed
Apgar Scoring: Reflex Irritability
response to stimuli such as gentle stroking motion along the spine or flicking the soles of the feet Apgar Score: 0= no response 1= response is a grimace 2= stimulation elicits a cry
Apgar Scoring: Color
assess for pallor and cyanosis Apgar Scoring: 0= blue, pale 1= pink body, blue extremities (acrocyanosis) 2= completely pink
Nursing Care for Fourth Stage of Labor
- midwife examines perineum, cervix, and vagina for evidence of tears
- nurse assess the uterus for firmness, height and position
- assess bloody discharge or lochia, noting color, amount, and presence of clots
- assess mothers vital signs frequently (q 5 to 15 minutes)
- monitors maternal urine output
Fourth Stage of Labor Signs of Danger
-hypotension, tachycardia, excessive bleeding, or boggy contracting uterus
>signs are associated with hemorrhage and be reported immediately
How to perform Fundal Palpation
-the left hand is placed directly above the symphysis pubis and gentle downward pressure is exerted
-the right hand is cupped around the uterine fundus
-on palpation the uterus is expected to feel firm and positioned in the midline, at or just below the umbilicus (like the size of a grapefruit)
>a full bladder or excessive blood in the uterus may cause it to be displaced from the midline
What happens if you find the uterus to be soft or “boggy”?
may indicate that excessive blood and/or clots have pooled in the uterus
-nurse immediately begins to massage the uterus until it becomes firm
>to perform massage; nurse uses 2 hands, one hand applies firm pressure to the fundus to express the blood clots, the other hand supports the lower aspect of the uterus to protect the ligaments from damage
-then assess lochia
Lochia
bloody or vaginal discharge
-note color, amount, and presence of clots
>first lochia that appears is bright red (lochia rubra)
>amount is determined by examining the soaking of the perineal pads and the frequency of pad changes required
Normal Lochia Vs Abnormal
- Normal: One soaked pad within the first postpartal hour; small clots common
- Abnormal: Large clots, a steady trickle of blood or pooling of blood under the buttocks can be a sign of trauma to the perineum or birth canal
Post-Partum Vital Signs Normal VS abnormal
assess q 5 to 15 minutes
-Normal: BP return to prelabor, pulse rate slower than recorded during labor
-Abnormal: a rising pulse rate or decreasing blood pressure= excessive blood loss
>a rise in temperature and increase in pulse may indicate postpartum infection
Monitoring Urine Output
a full distended bladder can displace the uterus and impede its ability to contract adequately, potentially leading to hemorrhage
-trauma to the urethra or bladder during childbirth may impair the mothers perception of the urge to void
Providing Comfort after Labor
- may experience shivering= provide heated blanket and warm beverage
- work of labor expended maternal energy= provide light meal and fluids to help replace lost calories
- encourage rest
