Intrapartum Flashcards
Factors that Stimulate Labor
How do we know that labor has started?
Onset of Uterine muscle contractions Oxytocin Estrogen Fetal Cortisol Prostaglandins
Changes in hormones!
Premonitory Signs of Labor (5)
Lightening Energy spurt “Bloody Show Braxton Hicks contractions Increase in clear; nonirritating vaginal secretions
Engagement
Relationship between mom’s pelvis and the presenting part of the baby passes the pelvic inlet Measurements = inlet, mid-pelvis, outlet
False Labor
No cervical change occurs
Discomfort usually in lower abdomen – more annoying than painful
Contractions irregular & short in duration
Intensity does not correlate with time
Medication and activity affect contractions
Usually no bloody show
Differentiation = contractions in false labor are more commonly irregular – healed with medications
Tylenol, hot shower, varying intensity, no cervical change
True Labor
Discomfort in front and back
Frequency, duration, and intensity increase
Palpable hardening of uterus
Pinkish mucous
Cervical Changes – Effacement, Dilatation
Bulging of membranes
Six concepts which make labor and birth as natural as possible are:
labor should begin on its own, not be artificially induced
women should be able to move about freely throughout labor, not be confined to bed
women should receive continuous support from a caring other during labor
interventions such as intravenous fluid should not be used routinely
women should be allowed to assume a nonsupine position such as upright and side-lying for birth
mother and baby should be housed together after the birth, with unlimited opportunity for breast-feeding
5 Labor powers
Powers
physiologic forces
Passageway
maternal pelvis
Passenger
fetus and placenta
Passageway & Passenger
pelvis and fetus
Psychosocial (Psyche)
influences
Primary and secondary power forces
Uterine contractions—primary force
Involuntary
Dilate the cervix
Maternal pushing efforts—secondary force
Voluntary
Compress the uterus -> birth of fetus
Uterine Contractions - Primary
Characteristics Frequency -- 10 minutes, 5 minutes, 3 minutes Duration Intensity Palpation: nose-chin-forehead
Uterine contraction graph
Pattern of contractions
Increment – up
Acme – peak – no blood flow to uterus
Decrement – down
Frequency – start of one contraction to start of another
Duration – start of one contraction to end of the same contraction
Intensity – how strong
EFM
Electronic fetal monitoring
to evaluate contractions
to assess fetus response to contractions
External monitor
Tocodynamometer
Electric monitor of uterine contractions
Internal monitor
Internal pressure catheter
Fetal scalp electrode – an internal fetal heart monitor
Intrauterine pressure cath – an internal contraction monitor
–> Membranes need to be ruptured
Maternal Pushing - Secondary
“Bearing down” sensation
Urge to push vs.No urge to push
10cm dilated – needs to feel urge to push
At 10cm can start encouraging to push but can become exhausted more frequently
Passageway
Passenger
Shape of pelvis can determine C/S – cephalopelvic disproportions
Fetus and fetal membranes
Fetal Head – sutures and bones can help tell provider where the baby is (occipital, frontal, parietal)
Fetal Lie – position baby is in compared to moms spine
Fetal Attitude
Fetal Presentation
Passenger - Fetal Lie
Longitudinal – can be longitudinal lie in breech position
Transverse
Oblique – diagonal
Fetal Presentation
Cephalic
Shoulder
Breech
Shoulder presentation
Fetus in transverse lie
Cannot be delivered vaginally unless rotated
Manual rotation performed by OB, CNM
Membranes must be ruptured, cervix dilated
Standard of care = C-Section
External rotation a month before
Painful; tight support strap, does not often work
Passenger - Presentation – BREECH
Breech
Complete – complete just facing the wrong way
Incomplete – butt down and one leg in air
Frank – two legs up
Footling – membranes ruptured and feel foot
Breech complications
Risk of cord prolapse
Presenting part less effective in cervical dilation
-> risk of prolonged labor
Risk of cord compression
Attitude
Flexed – want baby in this position
Vertex – 9.5
Extended
Military – 12.5
Brow –13.5
Face – 9.5
Passageway + Passenger
Fetal Position
“Landmark” = occipital bone
Landmark location vs. maternal pelvis
Back Labor
WANT LOA OR ROA – shorter labor, less pain
Station
Station – relationship of presenting part to ischial spines
Above ischial spines (–) minus station
“floating” not engaged
Ischial spines 0 station
engaged
Below ischial spines (+) plus station
“crowning” at +4 / +5
-> delivery
Psychosocial Influences (5th power) on Successful Labor and Delivery
Confidence in readiness
Educational preparedness
Cultural views of childbirth
Role transition facilitated by positive childbirth experience
Negative experience interferes with bonding and maternal role attainment
Stages of Labor
First stage
Onset of regular contractions to full dilation
First regular contraction = labor starts
Second stage
Full dilation to delivery of fetus
10cm
Third stage
Delivery of fetus to delivery of placenta
5 minutes to half hour
Fourth stage
1 - 4 hrs after delivery of the placenta (recovery
First Stage of Labor
Three phases
Latent phase 0 to 3 cm
0-30 secs, more than 5 mins
Active phase 4 to 7 cm
40-60 secs, every 2 to 5 mins
Transition 8 to 10 cm
60-90 secs, every 1 to 2 mins
Vaginal exams
Dilatation
Progress of labor
Plan interventions
Success of treatments – pitocin
If she is demonstrating changes in attitude or approach we don’t need to do a vaginal exam
Vaginal Exams
Station of the baby
Markers to identify
Palpate the sagittal suture
Identify the posterior fontanel
Identify the occipital bone
Identify the the anterior fontanel
Second Stage of Labor
Full dilation through birth of infant
Urge to push
Nursing interventions:
Promote effective pushing
Position of comfort
Assessment of fetal well being
Position Abdominal palpation (early labor) or Vaginal examination Ultrasound
Fetal heart sounds (FHR) Auscultation Doppler or Electronic Fetal Monitor
Interpret FHR, EFM
Contractions
Frequency
Intensity
FHR
Reassuring and non-reassuring (dips, brady, tachy changes above 25 bpm)
1 full minute – comparing peak to baby HR
Admission
Establish positive relationship Collect admission data Initiate admission interventions Physical assessment – mother and fetus Psychosocial assessment Cultural assessment Laboratory tests Initiate care plan in EMR Ongoing focused assessment and interventions
Labor Support
Promote comfort Personal hygiene Elimination Environment Presence Support relaxation
Women during labor are best supported by an RN
Shorter labors
Decreased pharmacologic use
Decreased operative vaginal or cesarean births
Decreased need for oxytocin
Increased satisfaction with birthing experience
Labor support
5 aspects
Emotional: encouragement, distraction, reassurance
Physical: touch, position change, heat or cold applications
Information: provide education, coaching, interpret medical jargon
Advocacy: support decisions, let other’s know her wishes
Support family: role model support, encouragement, provide breaks
Maternal positions in Labor
Hands and knees -- back labor Recumbent Upright Standing Sitting Side-lying -- back labor
Imminent Birth
7
Bulging of the perineum and rectum Flattening and thinning of the perineum Increased bloody show Labia begin to separate “Crowning” Burning sensation Intense pressure in rectum
Umbilical Cord Clamping
Cord clamped by HCP or father
Collect cord blood sample for laboratory analysis – test for baby blood type, cord blood for sampling
Cord blood storage arranged by parents
Immediate Care of Newborn
Airway Breathing Circulation Warmth Appraisal—Apgar score Identification of newborn
Third Stage
5
Birth of baby to complete delivery of placenta Lengthening and protrusion of cord Gush of blood from vagina Smaller, spherical uterus Elevation of uterus in abdomen
Nurse expects to admin oxytocin after expulsion of placenta to…
Stimulate contractions
Reduce incidence of post partum hemhorrage
Fourth Stage (6)
From delivery of placenta through 1 to 4 hrs
Monitor position and firmness of uterus –> “Boggy,” soft uterus –> Initiate fundal massage
Assess bleeding – lochia
Hypotension + Tachycardia – INDICATE BLEEDING*
Facilitate bonding
Initiate breastfeeding
Joint Commission Standards for Pain Management
Recognize the right: appropriate assessment and management of pain.
Screen patients: during initial assessment and reassessed appropriately.
Educate patients: pain management options and their family.
Pain Perception and Expression
Assessing pain
Physiological, psychological indicators
Increased catecholamines
Increased blood pressure and heart rate
Altered respiratory pattern
Patient responses
May be intensified by fear, anxiety, fatigue…
Shaped by past experiences
Cultural competencePain in Labor
Complex Multidimensional Pain management Non-pharmacologic Pharmacologic Goal: manage pain without interruption of labor or doing harm to mom or fetus Pain scale: Coping with Labor Algorithm
Pain in Labor
First and second stage
First stage – visceral pain: deep, dull and aching, poorly localized, felt only during contractions
Second stage - somatic pain: sharp, intense, well localized, burning, or prickling caused by stretching of perineal body, distention and traction, and soft tissue lacerations.
First Stage of Labor, Active
Pain
Dilatation of cervix
Stretching of the lower uterine segment
Pressure on adjacent structures
Hypoxia of uterine muscle cells during contractions
First Stage of Labor, Transition
Pain
Dilatation of cervix
Stretching of the lower uterine segment
Pressure on adjacent structures
Hypoxia of uterine muscle cells during contractions
Pain is really localized; can refer down to knees – localized around perineum
Second Stage of Labor
Pain
Pain
Hypoxia of uterine muscle cells during contractions
Distention of the perineum and vagina
Pressure on adjacent structures
Non-Pharmacological
Position changes and movement Standing Walking Slow dancing or leaning Rocking on hands and knees Pelvic rocking Side lying Squatting Bellydancing Massage Effleurage Counter Pressure Intuitive touch / therapeutic touch
Aromatherapy Breathing techniques Lamaze, Bradley Hypnobreathing Safety: valsava Compresses: warm or cold Relaxation techniques Visualization Focal point Imagery
Music Hydrotherapy Immersion Shower Biofeedback Tens unit
RN vs. Doula
Evidence based practice Meets woman at delivery Performs clinical tasks Consults and advocates Intermittent labor support Keeps patient informed Documents Legal accountability Minimal contact after delivery
Trained, may be certified Relationship during pregnancy Supportive role not clinical No communication with HCP Provides continuous support Informs pt using lay terms Assists in articulating questions or concerns to the nurse or HCP May document to share later Follow-ups after
Anti-Anxiety
Sedatives – for anxiety – not commonly given; anxiety will slow down
Barbiturates – rarely used
secobarbital (Seconal)
Benzodiazepines
diazepam (Valium)
lorazepam (Ativan)
Antiemetics – H1 Receptor Agonists
promethazine (Phenergan)
hydroxyzine (Vistaril)
diphenhydramine (Benadryl)
Pharmacological Pain Mgmt
Analgesics: Drugs that relieve pain without loss of muscle function. They lessen pain, but do not stop it completely.
RELIEF FROM PAIN
Anesthetics: Drugs that relieve pain through loss of sensation. They block all feeling.
LACK OF SENSATION
Analgesia
Increase pain threshold; reduces the perception of pain
Provide maximum relief of pain with minimal risk
Help patient relax and sleep between contractions
Analgesia Medications
Systemic Medications can cross the placental barrier
Analgesics used in labor:
Stadol, Nubain - 2-3 hr half-life (cross placenta, respiratory depression for baby, opioid preferred)
If given two hours before baby born – needs neonatologist
Dilaudid, Demerol - long half-life in neonate
Fentanyl, short-acting (needs repeated doses), may not cross placenta
May still cause respiratory depression
Analgesic Potentiaters
Decrease anxiety and increase effectiveness of analgesics (Phenergan, Vistaril)
Opioid Analgesics
Side effects
Nausea; Vomiting
Itching
Dizziness
More serious but not likely
Loss of protective airway reflexes
Hypoxia due to respiratory depression
Psychosocial concerns
“natural” birth
Hx of addiction
Antagonist
Systemic Analgesia – Opioids hydromorphone (Dilaudid) meperidine (Demerol) fentanyl (Sublimaze) butorphanol (Stadol) nalbuphine (Nubain)
Opiate Antagonist
Naloxone (Narcan)
Reverses effect – if sx of respiratory depression present
Can be used for mom or baby
DO NOT GIVE TO parent who has hx of addiction
Can cause seizures and can affect baby
Spinal and Epidural
Different spaces
Spinal into subarachnoid
Epidural into dura
Different locations
Spinal below L2 to avoid hitting spinal cord
Epidural into C T L spaces
Different onset
Spinal – faster acting
Epidural – slower acting
Epidural can be anesthesia and analgesia
Spinal only anesthesia
Spinal vs. Epidural
Complications
Regional spinal anesthesia block
Complications: Maternal hypotension Decreased placental perfusion Ineffective breathing pattern Spinal Headache -> tx with autologous blood patch --> Leakage of CSF
Regional epidural analgesia in labor, anesthesia in c/s Complications: maternal hypotension bladder distention prolonged second stage
Contraindication: Low Platelet count for BOTH
Epidural during Labor
Advantages and disadvantages
Advantages PCEA! Relieves discomfort during labor Fully awake during birth Fewer fetal effects --> no respiratory depression Mom rests before 2nd stage Fetus can labor down Access for LA morphine
Disadvantages
Maternal hypotension
Monitor VS; respiratory
Bolus before insertion
Epinephrine available
Limited mobility
Can slow fetal descent
Less effective pushing
Urinary retention – insert foley
Blood coagulation
Health Literacy
Health literacy – an interaction between system demands and people’s skills reading, writing, numeracy, listening, speaking, and conceptual knowledge
Duration of Pregnancy
1st trimester = 1-12 weeks
2nd trimester = 13-27 weeks
3rd trimester = 28-40 weeks
Gravida
Para
any pregnancy
delivery after 20 weeks regardless if born alive or stillborn, or how many infants
GTPAL
gravida – how many times pregnant
Term – infants before 37 weeks or more
Preterm – infants born at 20-36 (6) weeks
Abortion – elective or spontaneous before 20 weeks
Living children – survived neonatal period
Cardinal movements
baby turns when coming out to get head and shoulders out effectively
Membranes ruptured…
Abnormal labs…
Emergency
Assess FHR/pattern
Document characteristics and notify HCP
Palpate/auscultate abdo
Intervention PRN before documenting
Further orders – call HCP and then document
Quick assessment of ABCS
initiate rapid response
