Exam 1 - Labor and Birth Processes Flashcards
Components of the Birth Process:
The 5 P’s
- Passenger
- Passageway
- Powers
- Position
- Psych
- Passenger
- Fetus
- Membranes
- Placenta
Variations in the Passenger:
the 4F’s
a. Fetal Lie
b. Fetal Attitude
c. Fetal Presentation
d. Fetal Station
a. FETAL LIE
- The orientation of the long axis of the fetus to the long axis of the woman:
- - Longitudinal lie
- - Transverse lie
- The orientation of the long axis of the fetus to the long axis of the woman:
b. FETAL ATTITUDE
– The relation of the fetal body parts to one another. The normal fetal attitude is one of flexion.
– Flexion
– Extension (chin extended)
c. FETAL PRESENTATION
- The fetal part that first enters the pelvis is the presenting part.
- Presentation falls into three categories: cephalic, breech, and shoulder.
c. FETAL PRESENTATION (con’t)
–position:
1 – L or R
2 – O or M or S
3 – A or P or T
– by 35 or 36 weeks, we want the baby to be head down
Position: – 1st letter – either L or R – where occipital, chin, or Sacrum is facing – 2nd – what you feel when u touch: • O = occipital • M = Chin • S = Sacral – 3rd – • A = Anterior, • P = Posterior • T = Transverse – Where the heartbeat – to know the position of the baby – then via examination to know the presentation
d. FETAL STATION
– Negative is higher
– Positive means – baby is engaged and low
• Station describes the descent of the fetal presenting part in relation to the level of the ischial spines.
• Note:
– Ischial spine – how much diameter – if the baby is engage, means they are in the ischial spine and will not go back up !!
– Negative is higher
– Positive means – baby is engaged and low
- Passageway
- Maternal Bony Pelvis– the size determines if the mom can deliver vaginally
- Maternal Soft Tissues
- Powers
Kinds of POWERS:
1. PRIMARY (what the body is doing)
– Contractions
– Dilation
– Effacement
- SECONDARY (Mom pushing)
– Maternal Pushing
Primary Power: UTERINE CONTRACTION
DURATION – starts at 30 sec and makes longer and longer
FREQUENCY – from the start of a contraction to the start of the next contraction
INTENSITY –
RESTING INTERVAL – relaxing to get oxygen – resting in between the contractions
RESTING TONE – how tense the uterus in between contraction – should be completely relaxed
Primary Power: DILATION and EFFACEMENT
- 10 cm – for complete dilation
- - Don’t push when cervix is not completely dilated – to prevent complications
Secondary Power: MATERNAL PUSHING
– Techniques vary
– Prolonged pushing can lead to perennial trauma
– Breath holding can lead to fetal hypoxia
– Delayed pushing results in less fetal desaturation (waiting until woman feels the urge to push)
– Push while breathing out
- Position
– The actual position the mother assumes for labor and birth
- Psyche
- The most crucial part of childbirth
- Maternal catecholamines released in response to fear and anxiety can inhibit uterine contractility and placental blood flow.
• How do we help the psyche?
– If mom is convinced that she can do it, she can do it.
– how they look at thing can make a different
– Decrease the mom’s anxiety
Theories of onset of NORMAL Labor
– Decrease in progesterone with an increase in estrogen
– Increase in prostaglandins
– Increase in oxytocin
– Increase in oxytocin receptors
– Fetal Role
– Mechanical – what we do to manipulate the situation
Premonitory Signs of Labor
- Braxton Hicks Contractions
- Contractions – getting more intense
- Lightening –
- Increased vaginal mucous secretions – sign – mucous plug
- Cervical ripening and bloody show
- Energy spurt – mom becomes energetic
- Weight loss –
- Ruptured Membranes –
FOUR Stages of Labor
1st stage – CERVICAL EFFACEMENT and DILATION
• Latent: 0-3 cm
• Active: 3-8 cm
• Transition: 8-10 cm
2nd stage – stage of FETAL EXPULSION – the pushing
3rd stage – PLACENTAL EXPULSION – until placenta is delivered ( can last to an hour)
4th stage – RECOVERY → the most risky for hemorrhage for mom; contraction feeling means good bec that stops the bleeding
1st Stage –
LATENT
Signs:
- bloody
- cramping
- pressure/tightening
- loose bowels
- backache
- flu
- nesting
- contractions
Duration of Labor –
1st stage – CERVICAL EFFACEMENT and DILATION
• First Stage
– Latent: 8.6hr nullipara, 5.3hr multipara
– Active: 4.6hr nullipara, 2.4hr multipara
– Trans: 3.6hr nullipara, variable multipara
Duration of Labor –
2nd stage – stage of FETAL EXPULSION – the pushing
30min-2hr nullipara,
5-20min in multipara
Duration of Labor –
3rd stage – PLACENTAL EXPULSION – until placenta is delivered
3-60 minutes
Duration of Labor –
4th stage – RECOVERY
4 hrs (text states 2 hours) ??
Mechanisms of Labor: AKA Cardinal Movements of Labor
- Descent of Presenting Part
- Engagement of fetal presenting part
- Flexion of the fetal head
- Internal Rotation
- Extension of fetal head
- Restitution and external rotation
- Expulsion of head, shoulders, and body
Physiologic Adaptation to Labor: FETAL ADAPTATION
• Placental Circulation
– Fetal HGB
– High H/H
– Higher CO
• Cardiovascular
– Fetal heart Rate
• 110-160 bpm (average 140)
• Higher when preterm (average 160 bpm)
– Fetal Circulation
• Affected by maternal position, uterine cx, blood pressure, and umbilical cord blood flow
• during contractions, child BP should go up
• Pulmonary
– Fetal Respirations
• Fetal lung fluid is cleared from air passages during labor and vaginal birth
• Fetal O2 pressure (pO2) decreases
• Fetal CO2 pressure (pCO2) increases
• Fetal arterial pH decreases
• Fetal bicarbonate level decreases
• Fetal respiratory movements decrease during labor
Physiologic Adaptation to Labor:
Maternal Adaptation: REPRODUCTIVE System
Reproductive:
– Contraction
– Uterine
– Cervical
Physiologic Adaptation to Labor:
Maternal Adaptation: CARDIOVASCULAR System
Cardiovascular:
– Temporary increase in blood volume
– Supine hypotension
Physiologic Adaptation to Labor:
Maternal Adaptation: RESPIRATORY
Respiratory:
– Increased RR
– at Risk of Hyperventilation
• for light headed, tingling/numbness on face, need to rebreathe the CO2
Physiologic Adaptation to Labor:
Maternal Adaptation: GI & GU
Gastrointestinal:
– N/V
Urinary:
– Decreased Sensation of Bladder Fullness
– Need bladder to be emptied bec they can not control or feel if the bladder is full
Hematopoietic: – Blood loss during L&D • 800 cc or less blood loss for CS • 500 cc or less for vaginal blood loss – Increased levels of clotting factors
Physiologic Adaptation to Labor:
Maternal Adaptation: INTEGUMENTARY
NEUROLOGIC
ENDOCRINE
Integumentary:
– Distensibility in the area of the vaginal intraoitis
Neurologic
– Sensorial changes
Endocrine
– Labor is triggered by decreased progesterone and increase estrogen, and increased prostaglandins, and oxytocin
Natural delivery
means NO epidural but can get pain meds through IV
Expression of Pain
• Respirations increase (hyperventilation common)
• Gastric acidity increases (N/V)
• Emotional: tiring, exhausting, annoying, sickening, nauseating, anxiety, writhing, crying, groaning
• Sympathetic nervous system stimulated and results in catecholamine release
– Increased heart rate
– Increased blood pressure
• BP shld NOT be over 140/90
Factors Influencing Pain Response
- Physiologic
- Culture
- Previous Experience
- Comfort
- Support
- Environment
Factors that Influence Perception or Toleration of Pain
- Intensity of Labor
- Cervical Readiness
- Fetal Position
- Characteristics of the Pelvis
- Fatigue and Hunger
- Intervention of Caregivers
Nonpharmacologic Pain Management
- Advantages: Do NOT slow labor and have no side effects
* Disadvantages: Some not able to achieve desired level of pain relief
Nonpharmacologic Techniques OF PAIN Management
– Focusing and Relaxing
• Reduces tension and stress
• Attention-focusing and distraction techniques (focusing on an object)
-- Cutaneous Stimulation
• Effleurage and counterpressure
• Water Therapy
• Application of Heat and Cold
• Touch and Massage
-- Breathing techniques
-- Meditation
-- Environmental Changes
BREATHING TECHNIQUES
• First Stage Breathing
– Always start and end a contraction with a Deep Cleansing Breath
– Slow paced (latent)
– Modified paced (active)
– Patterned paced (transition)
– Breathing to prevent pushing (pursed lip)
• Second Stage Breathing
– Limit breath holding
• Do not hold breath while pushing bec baby will become hypoxic
• Encourage the patient to breath during pushing
Pharmacologic Pain Management
Pharmacologic Pain Management:
• Any drug taken by the woman is likely to affect the fetus
• Drugs can affect the course and length of labor
• Pregnancy complications may limit the choice of pharmacologic pain management
Systemic PAIN Drugs for Labor
Systemic Drugs for Labor:
• Have effects on multiple systems because distributed throughout the body
• Parenteral Analgesia
– Opioid/Sedatives
– Opioid Antagonist
• When resp is low, DON’T give sedatives/opioids
• Opioid Antagonist – not given to addicts – bec they will have an INSTANT WITHDRAW – !!!!
Ex. Nubain, Stadal —NO! NO! NO!
PAIN MANAGEMENT Procedure
Procedure:
• Assess pain level
• Estimate time of delivery
• Educate patient
• Check for order/call care provider if order needed–SBAR
• Evaluate if medication appropriate for patient
• Evaluate Fetal Heart Rate (don’t give if FHR is low)
• Administer med according to the 7 rights
– When do you give the med?
– IV Push—slow
• Assess maternal and fetal response
– What is expected, what is an adverse effect?
– Timing
• Baby has to look good before I give pain med.
• Administer the pain meds while in contraction
Vaginal Birth Anesthesia (kinds)
- Local Infiltration Anesthesia
* Pudendal Block
Local Infiltration Anesthesia
Local Infiltration Anesthesia:
• Infiltration of the Perineum with a local anesthetic → Just numbing the perineum – lidocaine
• Can be performed by physician or CNM
• Does not alter pain from contractions or distension of the vagina
• Used for episiotomy or laceration repair
• Rarely has adverse effects for mother or fetus
Pudendal Block Anesthesia
Pudendal Block
• Anesthetizes the lower vagina and part of the perineum
• Provides pain relief for episiotomy and vaginal birth
• Does not block contraction pain
• Highly localized
• Complications: Reaction to anesthetic, rectal puncture, hematoma, sciatic nerve block.
• Fetus usually not affected
Regional Pain Management (kinds)
Regional Pain Management
• Epidural block
• Intrathecal opioid analgesics
• Subarachnoid (SPINAL) block
Lumbar Epidural Block
Lumbar Epidural
• Used for both vaginal and Cesarean births
• Injection of local anesthesia through a catheter into tiny epidural space at about L-3, L-4
• S/E: maternal hypotension, Bladder distention, Prolonged second stage, catheter migration, c-section, maternal fever, N/V, pruritis, delayed respiratory depression
– maternal hypotension – need a liter of fluid bec epidural can lower their BP; also need platelet count à contraindicated to pt w/ risk of bleeding,
EPIDURAL : Nursing Considerations
Epidural: Nursing Considerations
• Before epidural
– Fluids
– Platelets
– assess Fetal Heart Rate
• During epidural
– Positioning
– Support
– Fetal Heart Rate
• After epidural
– Assess BP for hypotension and Fetal Heart Rate for tolerance
– Left Side-Lying Position
– If hypotension occurs, initiate intrauterine resuscitation !!!!!
– Manage other side-effects as necessary
– Assess for return of sensation/assist with ambulation
Intrathecal Opioid Analgesics
Intrathecal Opioid Analgesics:
• The drug is injected into the subarachnoid space, where it binds directly to opioid receptors allowing much smaller doses of the medication
• Limited duration of action
• N/V, pruitis
• Advantageous b/c does not cause hypotension
– Assess for return of sensation/assist with ambulation
Subarachnoid (SPINAL) Block
Subarachnoid (Spinal) Block
• Simpler than epidural
• Performed when a quick C-Section is necessary, performed just before birth
• Local anesthetic injected into subarachnoid space
• Adverse Effects: maternal hypotension, bladder distension, and postdural puncture headache
– Do this just before they take the baby out !!
– Quick acting and short acting !!
– Risk S/E – HA
SPINAL BLOCK: Nursing Considerations
Spinal Block: Nursing Considerations
• Hypotension a concern (see epidural considerations)
• After Spinal
– Foley Catheter Necessary
– Post Anesthesia Recovery and Assessment for return of sensation/assist with ambulation when permitted
– Patient at risk for CNS depressant symptoms for 24 hours after medication insertion into spinal and special precautions in effect for 24 hours
• Frequent respiratory and vital sign assessment
• Decreased doses of pain medications related to compounding effects of CNS depression
• Antidote
• Always assess the respiration !!
• Antidote is narcan
Postdural Puncture Headache
Postdural Puncture Headache
• Occurs because of CSF leakage
• Worse when woman is upright and disappear when lying flat
• Tx: bedrest with oral hydration, caffeine, blood patch
General Anesthesia
General Anesthesia:
- For Emergency C-Sections
- Planned C-Sections when woman not a candidate for epidural or spinal
Special Considerations:
- General Anesthesia can affect the fetus; therefore, once anesthesia is administered the baby must be delivered quickly !!!
- Post Anesthesia Recovery
