Chapter 9: nursing care during labor and childbirth Flashcards
labor
a physiological process during which the fetus, umbilical cord, placenta, and amniotic membranes are expelled from the uterus, accomplished through uterine contractions, cervical effacement and dilation
- usually begins between 38 weeks and 42 weeks of gestation
theories about the onset of labor
- increased levels of oxytocin
- oxytocin stimulates prostaglandin production
oxytocin
a pituitary hormone secreted into the bloodstream that stimulates the uterine muscle, causing myometrial activity
proaglandins
hormone-like substances which affects tissues, including contraction and relaxation of the smooth muscle, causing cervical softening and increased uterine muscle sensitivity
the placenta produces progesterone, which relaxes…
uterine muscle by hindering impulse conduction; progesterone levels decline toward the end of pregnancy, allowing estrogen to stimulate contractions
the corticotropin releasing hormone hypothesis
maturing fetus produces cortisol; the placenta then converts it into estriol. rising levels of estriol produces an imbalance with estradiol, triggering labor
the uterine stretch theory
uterus becomes overstretched, leading to a natural expulsion of the contents
uterine muscle layers
external
internal
middle
external uterine muscle layer
arches over the fundus and extends to the ligaments supporting the uterus
internal uterine muscle layer
has fibers that act as sphincters around the opening of the fallopian tubes and internal opening of the cervix
middle uterine muscle layer
composed of dense network of fibers and blood vessels that contract after placental delivery to prevent blood loss
musculature changes in the pelvic floor
- Levator ani and fascia pull the vagina and rectum upward and forward with each contraction
- pressure of the fetal head causes these muscles to thin from 5cm to 1cm at the time of birth
signs of labor: bloody show
- blood tinged mucus (mucous plug) from the cervix noted any time before or during labor
- not everyone has it, different from bleeding. mucusy blood tinged slime
signs of labor: burst of energy
- “nesting” wherein the woman wants to complete many projects before the baby’s arrival, noted about 24-48 hours before labor begins
signs of labor: spontaneous rupture of membranes (SROM)
- “water breaking” manifested as a large gush or a small trickle of fluid
- may rupture any time during labor
- fluid should be clear with no offensive odor
- a yellow or green (meconium)amniotic fluid may indicate an unhealthy fetus, should be reported immediately to the hcp –> hypoxia, aspiration
- some women don’t rupture and needs to be artificially ruptured
signs of labor: lightening
noticed by the mother after the 38th week of pregnancy after engagement occurs
engagement
the fetus descends or drops into the pelvis
signs of labor: contractions
- Braxton Hicks contractions are irregular, mild contractions that begin during the second trimester and do not produce cervical effacement and dilation
- in true labor, uterine contractions are regular, become more intense as time passes, and may radiate from the lower back or pelvis to the abdomen
- the contraction start mildly, gets stronger, progresses to a peak, and then fades away
effacement
the cervix-thinning process caused by the shortening of the muscles of the upper uterine segment and longitudinal traction on the cervix
- measured in percentages; a thick uneffaced cervix is 0%, a fully thinned cervix is 100%
dilation
the opening of the closed cervix to approx 10cm or large enough to accommodate the fetal head
dilation and effacement is faster for the…
second and subsequent labors
true labor contractions
- regular intervals
- increasingly more intense as labor progresses
- increased duration over time
- discomfort usually begins in the back and radiates to the front
- cause effacement and dilation
- may intensify with walking
- unchanged w/ warm shower or rest
difference between true and false labor contractions
- do nt increase in duration
- do not cause cervical effacement and dilation
- may cease w/ rest or a warm shower
- do not intesify w/ walking
critical factors in labor: “7 P’s”
passage
passenger
powers
position
psyche
pain management
patience
passage
- the route through which the fetus must pass to be delivered vaginally
- the pelvis: most im portant to the outcome of labor; must be measured by the hcp at the first prenatal visit to determine if size is adequate for a vaginal delivery
- the hormone relaxin causes softening of the cartilage, allowing the pelvis to stretch and llowing the pelvis to stretch and allow passage of the fetus; relaxin affects all joints of the body, making the term pregnant woman at risk of falling due to the loosening of her pelvic joints, knees, ankles
- yield to the pressure of the fetal presenting part, usually the head
passenger
- refers to the fetus w/ the placenta
- fetal head: the frontal, parietal, and occipital bones are not fused to allow the bones to overlap as the head passes through the pelvis (molding)
- the optimal position for the fetal head at birth is fully flexed w/ chin on chest
- fetal lie: position of the fetus in the uterus referring to how the fetal spine lines up w the mother’s spine: longitudinal, transverse, oblique
longitudinal lie
a fetus that is lying parallel w/ mother
transverse lie
a fetus is lying perpendicular to the mother’s bodyob
lique lie
a fetus that is lying at an angle between longitudinal and transverse
fetal presentation
cephalic: head is the presenting part most common and easiest to deliver
shoulder: will require c section
breech: buttocks are presenting part
footling breech: feet are presenting part
fetal position
first letter: indicates whether presenting part is tilted towards left or right ofmaternal pelvis
second letter: indicates presenting part of fetus o for occipital or s for sacrum
third letter: indicates the location of the presenting part in relationship to the anterior, transverse, or posterior part of the maternal pelvis
fetal attitude
refers to the positioning of the fetus’ body parts
fetal station
measurement in cm of the fetal head in relationship to the maternal ischial spines in the pelvis
ranges from -5cm to +5cm
powers
- refer to the power of the uterine contractions and the woman’s ability to push
phases of uterine contractions
increment
acme
decrement
increment
onset and build up of inensity of the cotraction
acme
peak of the contraction
decrement
the subsiding of the contraction
descriptions of contractions
onset
duration
frequency
intensity
onset
the exact time a contraction begins
duration
the actual time a contraction lasts from beginning to end
frequency
the time between the beginning of one contraction to the beginning of the next contraction
intensity
the strength of contraction at its peak
it is important to teach the pregnant woman how to time…
uterine contractions by noting the onset, duration, and frequency of the contraction; this well help distinguish between true and false labor
how to time uterine contrctions
- note the exact time a contracti begins
- note the exact time a contraction stops
- note the exact time that the next contraction begins
position
- upright positions (standing, sitting, kneeling, or walking) reduce the length of labor by approx 1 hour and are associated w/ less epidural aneshesia
- upright, lateral, or squatting positions for pushing and delivery reduces the need for assisted delivery and have been shown to reduce severe pain and abnormal fetal heart rate patterns
- allow the pt to choose position of comfort except for supine, which can caus eblood flow problems for the woman and the placenta
- encourage women w/out an epidural to deliver in an upright position
psyche
- refers to the woman’s state of mind
- physical and mental preparation are very important
factors that contribute to a positive birth experience
childbirth education
trust in the hcp and staff
integration of the pts birth philosophy, cultural beliefs, and religious values and beliefs into the plan of care
pain management
- childbirth is a painful prcess
- every woman perceives and reacts to pain differently
non pharmacological pain management methods
massage, warm baths, and relaxation techniques, birthing ball, tubs
patience
delaying interventions such as induction of labor, augmentation of labor w/ oxytocin, and epidural anesthesia may decrease medical interventions and cesarean birth rate
methods to increase patience
- educate pt and family
- avoid interventions that reduce the ability to push
- avoid induction of labor when cervix has not softened
- avoid induction for non medical reasons
- provide reassurance
- provide non pharmacological pain interventions as well as pharmacological support for pain
- if the fetal monitor indicates the fetus is healthy do not rush the birth; allow a longer pushing phase
cardiovascular system
- at the peak of contractions blood flow to the placenta from the mother decreases
- blood volume increases
- blood pressure rise and decreases pulse rate
- supine hypotension may occur if lying on the back
- encourage labor in a side position or slightly upright to avoid hypotension
respiratory system
- anxiety and pain caused increased rate and depth of respirations
- hyperventilation can occur due to exhaling too much carbon dioxide
renal system
- fetus places pressure on the bladder
- full bladder can impede labor and fetal descent
- encourage pt to urinate at regular intervals
- a woman w/ an epidural during labor will have a catheter inserted to keep the bladder from becoming too full
GI system
- gastric motility slows down
- n/v can occur during labor so large quantities of food and liquids are not advisable
- thirst and dry mouth are common due to increased respiratory rate
hematopoietic system
- expected blood loss for a vaginal delivery is 500ml
- hemoglobin level of 11 g/dL and hematocrit of 33% or higher indicates that the woman can andle the blood loss w/out problems
- leukocyte count is usually higr averaging 14-6/mm3
- fibrinolysis slows down, promoting coagulation when the placenta separates from the uterus
fetal responses to labor
- heart rate accelerates w/ fetal movement; decelerates w/ head compression
- decreased circulation and perfusion during the peak of a contraction
- increased arterial carbon dioxide pressure
- decreased fetal oxygen pressure
- decreased fetal breathing movements
settings for childbirth
- there are a variety of settings that can be used by women w uncomplicated pregnancies
- hospital
- birthing center
admission to the hospital or birthing center
- complete paperwork and supply insurance and payment information prior to arriving in labor
- consent for admission and medical and nursing care
- admission data collection
- nurse will review records
- medication history including current medications, vitamins, supplements, or alternative therapies
maternal care
- obtain a baseline
- assess contractions, cervical dilation, and fetus
- complete admission assessment
- vital signs
- allergies to food and medications
- documentation of last food intake
- complete head to toe assessment
- skin assessment
- fall risk assessment
- pain assessment
- cultural needs
- documentation of time labor began; frequency and duration of contractions
- presence or absence of bloody show
- cervical exam
cervical examination
- performed periodically to determine cervical dilation, effacement, and fetal position
- consider the woman’s partiy, past labor length, contraction pattern, and response to labor to determine the frequency
- never perform if the woman is bleeding, bleeding may indicate placenta previa and exam may lead to puncture of the placenta and hemorrhage (nurse’s don’t typically do this)
assessment of amniotic membrains
- obtain the time of rupture and the characteristic of the fluid (color, odor, amount)
- amniotic fluid should be clear
- report any abnormalities to the provider immediately
- Nitrazine paper alkaline fluid such as amniotic fluid will produce a deep blue color on the paper
laboratory tests
evaluates red blood cells, wbc, and platelets
provides information about the general health of the pt
blood type and screen
evaluates blood type and Rh
in prep of blood transfusion if needed
urinalysis
screens for infection, gluco, bilirubin, nitrates, and proteins
provides information on pts overall health
group b strep
- done at 37 wks gestation or by rapid GBS test kit
- positive result can expose the fetus and cause pneumonia and sepsis in the newborn
- penicilin G is the drug of choice; ampicillin is an alternative choice
birth plan
- review it w/ the pt and make sincere efforts to follow the plan if not interfering w/ a safe birth
- explore options that may be agreeble to the pt and health care team if the team cannot safely adhere to the complete birth plan
support person
- determine the main support person and ensure the staff will also provide an additional needed support
- doula: a trained and experienced professional who provides physical, emotional, and informational support during labor may be present
childbirth classes
- be prepared to support and assist w/ breathng relaxation techniques if pt attended the Lamaze or Bradley classes
- teach relaxation and breathing techniques if pt has not attended any birthing classes
fetal assessment
- perform Leopold’s maneuvers: a series of palpation done to determine fetal position and presentation
- provides info on posible complications in labor; easier positioning of the electronic fetal monitoring equipment
- after leopold’s maneuvers obtain a baseline fetal heart rate (FHR) assessment using a handheld Doppler device
- after determining the baseline discuss a plan to intermittently or continuously monitor fetal well-being
signs or symptoms that can indicate a problem and must be reported to the provider immediately
- temperature greater than 38 degrees Celsius (100.4 Fever)
- BP greater than 140/90 mmHg or less than 90/60 mmHg
- maternal heart rate greater than 110 pm
- respiratory rate greater than 24 breaths per minute
- vaginal bleeding
- abnormal FHR pattern
fetal monitoring
- done to detect signs that the fetus is not tolerating the stress of labor
- one important factor is fetal oxygenation status; any disrupon will cause deceleration of the FHR and possible hypoxia; abnormal decelerations require PROMPT interventions
signs or symptoms that can indicate a problem and must be reported to the provider continued
- uterine contactions lasting 2 minutes or longer or occurring within 1 minute of each other
- any abnormal finding from physical assessment
- impending delivery
intermitten fetal monitoring
handheld doppler device: uses ultrasound waves that bounce off the fetal heart, producing echoes reflecting FHR
- fetal monitor: apply and obtain a 20 minute evaluation then remove
- allows the woman to move around
- disadvantages: cannot evaluate variability and decelerations
continual fetal monitoring
- done w/ a fetal monitor applied externally or internally
- consider continuous monitoring of high risk women during labor
- indications for continuous fetal monitoring: hypertensive disorders, preterm labor, post term pregnancy, maternal cardiac disease
- oligohydramnios or polyhydramnios
- multiple gestation
- induction of labor
- administration fo epidural anesthesia
- vaginal birth after cesarean
- diabetes
intrauterine pressure catheter (IUPC)
- a small flexible tube inserted into the uterine wall that provides exact measurement of contraction length and intensity
- inserted by an obstetrician or nurse midwife through a guide tube through the cervix and into the uterus
- initiated if more information is required regarding uterine activity, especially the intensity of the contractions
external monitoring
- start w/ hand hygiene and perform leopold’s maneuvers
- apply ultrasound gel to the transducer; place transducer over the fetal back then secure the transducer w/ a belt around the woman’s abdomen
- external monitoring of the FHR provides information about heart rate baseline, variability, accelerations, and decelerations
tocodynamometer
used to measure the frequency and duration of uterine contractions; place on the fundusu of the uterus and secure w/ a bel
- the transducer and tocodynamometer send a signal to the fetal monitor and is recorded on the monitor paper
application of a fetal scalp electrode (FSE) to directly monitor fetal heart
- an experienced nurse advances the electrode through the vagina and attaches it to the presenting part
- initiated by the nurse if the external method does not provide reliable information regarding fetal condition
principles that can be applied to FHR interpretations
- all significant decelerations indicate interruption in oxygen to the fetus
- a disruption in fetal oxygenation can result in hypoxia for the fetus
- fetal neurological injury will not occur if hypoxemia is corrected and significant acidemia does not occur
variability
refers to the fluctuations in the baseline that are irregular in frequency and amplitude
- persistent absence or minimal variability is the most significant sign of fetal distress; possible causes are fetal metabolic acidosis, fetal sleep cycles, prematurity, congenital anomalies, cns depressants, and Betamethasone
accelerations
an abrupt increase in FHR above the baseline
- predict adequate fetal oxygenation
- fetal ovement usually results in accelerations
- absence for more than 80 minutes is associated with neonatal morbidity
decelertion
decrease in FHR from the baseline
episodic decelerations
drops in the FHR not associated w/ uterine contractions
- periodic decelerations are drops in FHR associated w/ uterine contractions
visceral pain
refers to the pain in internal organs and is caused bya ctivation of receptors in the chest, abdomen, or pelvic area that send signals to the spinal cord and on to the brain
- particularly present during the active and transition phases of labor along with uterine pain
somatic pain
- caued by activation of pain receptors in the body surface or musculoskeletal tissues
- present when the fetal head begins to descend and stretching of the perineum occurs
nonpharmacological pain management
- relaxing environment
- display a relaxing picture as focal point
- play relaxing music or sounds
- aromatherapy
- massage or strokes
- progressive relaxation by conversation
- use of pillows
systemic analgesics
butorphanol, meperidine, morphine, fentanyl, nalbuphine hydrochloride
- most commonly given IV but may also be given IM
- do not totally eliminate pain but will promote comfort and relaxation
- IV administration has a prompt onset and with smaller doses
- side effects that may occur are nausea/vomiting, drowsiness, sedation, respiratory depression, and neonatal respiratory depression
nursing responsibilities for systemic analgesics
- review pts drug allergies prior to administration
- assess pain
- ensure labor is well established ebfore administration
- do not administer narcotic analgesics within 1 hour of delivery may cause neonatal respiratory dpression
- provide a higher dose of medication to women w/ history of substnce use disorder
inhaled nitrous oxide
can be used for procedures such as perineal repair or manual removal of the placenta
regional analgesics and anesthetics
- techniques include pudendal block: injection into the pudendal nerve, epidural, spinal, or a combination of epidural and spinal anesthesia
pudenal block
- anesthetizes the vulva and perineum
- dvantages include pain control from perineal stretching; provides continuous anesthesia for episiotomy repair
- nursing care includes monitoring for urinary retention and for signs of infection
epidural anesthesia
- an effective form of pain relief administered w/ a small needle and catheter between the 4th and 5th vertebrae into the epidural space, causing blocked pain sensation in that area
- advantages include complete pain relief, no respiratory depression for the fetus
- disadvantages are slowing labor for about an hour after administration; pts blood pressure drops immediately; requires the use of a urinary catheter; may cause numbness or tingling on pts legs and feet; will prevent pt from walking; prolongs stage 2 of labor; may cause fever and itchiness; makes pushing difficult; can inadvertently penetrate the dura and cause spinal headache; may lead to vacum extraction delivery of the fetus
a major complication of epidural anesthesia is the …
inadvertent fusion of the anesthetic into the intravascular space instead of the epidural space causing tachycardia or bradycardia, hypertension, tinnitus, dizziness, and metallic taste and may lead to cardiac arrest; provider must be notified immediately if any of these signs occur
local anesthesia
injected into the perineum for fast temporary relief of stretching pain during delivery, repair of any tears, or an episiotomy
- numbs the area but no relief from contractions
- does not harm the baby
- commonly used medications include lidocaine, procaine, or tetracaine
general anesthesia
- used in cesarean births
- medication is given by IV after loss of consciousness, an endotracheal tube is placed to allow administration of oxygen and gas to keep pt unconscious until birth is over
- disadvantages are effecs on the fetus; the woman is at risk for aspiration that can lead to pneumonia
episiotomy
an incision into the perineum, allows more room for the fetal head and prevents large tears in the perineal
- avoid if possible
- provider will check for a tight umbilical cord aound the neck as the head emerges; if tight cord is present it may need to be clamped and cut before the body emerges
- provider will suction the newborn’s mouth and airway before the chest emerges
COVER THE BABY’S HEAD
signs of placental detachment
- the umbilical cord lengthens
- the uterine shape becomes firmer, rounder, and moves up in the abdomen
- a gush of blood occurs
nursing care birth through delivery of the placenta
- administer oxytocin as ordered
- provide assistance to the provider
- assume care for the newborn with emphasis on the airway and warmth
- assess the umbilican cord for TWO ARTERIES AND ONE VEIN
- perform apgar assessment
