Intrapartum Assessment and interventions ch 8 Flashcards

Question

Culture

Answer 1

The nurse must be culturally aware and sensitive to the needs and practices of the individual by integrating the woman’s cultural and religious values, beliefs, and practices to provide a mutually acceptable plan of care.

Answer 2

Culturally sensitive communication is open, respectful, and nonjudgmental, and acknowledges that the nurse is willing to learn Giving birth is a pivotal life event, and the meaning of birth and parenthood is culturally defined Culture influences all aspects of a woman’s response to labor and impacts factors such as: ● Who is with the woman in labor, their role, and who participates in decision making ● Preferences for use of pharmacological and non-pharmacological pain management in labor ● Who the woman wants to care for her in relation to gender and modesty ● Response to labor The nurse must consider these factors to help women formulate their concerns, priorities, and decisions during childbirth. It is important for nurses to have a general understanding of birth practices of the cultural groups prevalent in the area where they work it is essential in the delivery of quality and safe care to childbearing women and their families. By identifying the patient’s beliefs and being sensitive to her experiences of the health care system, nurses can provide individualized care to the women and her support system and give helpful information and guidance when differences are encountered.

Answer 3

Ethnicity, race, and religion may influence a woman’s values, practices, and preferences during labor and birth. A flexible approach to care is required to meet the individualized needs of the woman during labor and birth. Nurses should be knowledgeable of the customs and beliefs of the specific cultural groups receiving care.Providing individually focused, culturally sensitive care may enhance the likelihood of a positive birth experience. This may include the following measures: ● Learn the traditions of the cultural groups you often care for and the specific preferences of each woman and her family. ● Recognize there are subcultures within cultures. ● Listen to the woman and her support persons and help them find meaningful and acceptable support activities. ● Identify who the client calls “family.” ● Expectations for the role of the woman’s partner regarding support behaviors during labor and birth may vary greatly from one culture to the next. ● Use the beliefs, values, customs, and expectations of the woman to shape her plan of care for labor and birth. ● Include notes on cultural preferences and family strengths and resources as part of all intake and ongoing assessments and nursing care plans. ● Instead of focusing on technology, look beyond the routine and appreciate the needs of each woman. ● Develop linguistic skills related to your patient population. ● Learn to use nonverbal communication in an appropriate way. ● Learn about the communication patterns of various cultures. ● Recognize and acknowledge your own belief system while maintaining an open attitude. ● Examine the biases and assumptions you hold about different cultures. ● Avoid preconceptions and cultural stereotyping. ● Recognize all care is given within the context of many cultures. ● Advocate for organizational change that is flexible to cultural variations.

Answer 4

The nurse should review the woman’s expectations to help alleviate fear and to help set realistic goals. ● Unrealistic expectations can cause an increase in maternal anxiety. ● Past experiences and complications of pregnancy, labor, and birth strongly influence women’s expectations of labor and response to labor. ● Women who have experienced a negative previous birthing experience are at risk for increased anxiety; women who experienced a positive previous birthing experience have lower anxiety levels. ● Women who are recent immigrants may have had very different birth experiences in other countries, and that influences their expectations, hopes, and fears. ● Current pregnancy experience with difficulty conceiving, an unplanned pregnancy, or a high-risk pregnancy may increase a woman’s anxiety and fears.

Answer 5

continuously available labor support from a registered nurse (RN) is a critical component to achieve improved birth outcomes. The RN assesses, develops, implements, and evaluates an individualized plan of care based on each woman’s physical, psychological and socio-cultural needs, including the woman’s desires for and expectations of the laboring process. Labor care and labor support are powerful nursing functions and it is incumbent on health care facilities to provide an environment that encourages the unique patient-RN relationship during childbirth. For women in labor, continuous support can result in the following: Shorter labor • Decreased use of analgesia/anesthesia • Decreased operative vaginal births or cesarean births • Decreased need for oxytocin/uterotonics • Increased likelihood of breastfeeding • Increased satisfaction with the childbirth experience Non-pharmacologic methods of supporting and comforting women in labor have been shown to be therapeutic and to impact on women’s experiences and birth outcomes. continuous support during labor may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labor, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score, and negative feelings about childbirth experiences.

Answer 6

The woman’s perception of being able to maintain control during labor and delivery is an important contributing factor to a positive and favorable evaluation of childbirth. This includes control of pain perception, control over emotions and actions, and being able to influence decisions while being an active participant. the patient experiences decreased anxiety and feels more in control. Nursing care of women in early or latent labor should incorporate the following types of support and interventions: ● Encourage her to do normal, distracting activities and rest as needed. ● Provide emotional support, including continuous presence, reassurance, and praise. ● Provide information about labor progress and advice regarding coping techniques. ● Offer comfort measures (e.g., comforting touch, massage, warm baths/showers, promoting adequate fluid intake and output). ● Serve as an advocate, including assisting the woman in articulating her wishes to others.

Answer 7

Supportive Care for Adolescents in Labor Adolescents may have a very different view of labor and birth as they struggle with self-identity and self-esteem. It can pose a challenge for providers and nurses to work with adolescents to promote a positive birthing experience, and they must understand adolescent development, expectations, and needs to do so. According to Sauls (2010), four themes became apparent based on feedback of over 180 adolescents in three tertiary centers during their postpartum interviews: • Respectful nurse caring: During interactions, be kind and friendly and make her feel welcome. Include her in decision making, informing her of her options related to her care. • Assistance with pain control: Assist her with pain management options with explanations of both pharmacological and non-pharmacological choices. Assess often her ability to manage her pain. • Nursing support of the adolescent’s support person: Pay attention to her support person’s emotional and physical needs. Encourage them as they work through labor, including them in explanations and plan of care discussions. • Childbirth guidance: Orient her and her support system to hospital facilities and to the birthing process, anticipating questions and explaining procedures. Answer questions truthfully and in an age-appropriate manner. Nurses should establish environments in which adolescents’ rights are protected. Pregnant adolescents often require special care and attention during the second stage of labor. The young adolescent has fewer coping mechanisms, less experience to draw on, incomplete cognitive development, fewer problem-solving capabilities, and an ego identity that is more easily threatened by the stress and discomfort of labor. Interventions that support the normal physiologic processes of the second stage of labor should be age- and developmentally appropriate for adolescents.

Answer 8

the birth plan must consider issues surrounding labor support, who will be with the birth mother, and the extent of the adoptive parents’ involvement in the labor and after birth. When preparing the birth plan, birth mothers should be asked if they want the prospective adoptive parents to be present for the birth, whether in the waiting room or in the labor room itself, or whether they prefer the adoptive parents remain at home during labor and birth. Commonly, birth mothers decide to have some time alone at the hospital. This gives them a chance to feel settled in the decision and make peace before placement. Supporting the wishes of the birth mother is the priority and duty of the nurse caring for the laboring woman. The experience of birth and the moments after belong to the birth mother, and nurses must allow the birth family to have their time. When the adoptive parents will have contact with the newborn is the birth mother’s decision in most situations. Because society views the relinquishment of an infant as a voluntary choice, there may be no acknowledgment that a loss has occurred, and thus no expectation for the birth mother to go through a grief process with subsequent adjustment. Relinquishing mothers value and need someone who will support them and their interests at this vulnerable point in their lives. The attitudes of the health care provider can affect how much control the relinquishing mother has over the adoption process. . Nurses involved with women at the time of relinquishment can be of significant help in the resolution of grief.. Postpartum telephone calls and/or support groups may be beneficial in this area. Referrals for long-term counseling may be needed.

Answer 9

The practice of gestational surrogacy involves a woman known as a gestational carrier who agrees to bear a genetically unrelated child with the help of assisted reproductive technologies for an individual or couple who intend(s) to be the legal and rearing parent(s), referred to as the intended parent(s.Although gestational surrogacy increases options for family building, this treatment also involves ethical, medical, psychosocial, and legal complexities that must be considered to minimize risks of adverse outcomes for the gestational carrier, intended parent(s), and resulting children. Generally, the surrogate accepts responsibility to maintain the pregnancy and perform conventional measures for fetal growth until the child is born. In surrogacy, families have a business agreement surrounding the pregnancy and birth, so multiple families are involved in the hospital stay.State laws surrounding these arrangements vary and are evolving, and clear policies and procedures that outline the legal processes are needed. Nurses are integral for a smooth process of care and to promote satisfaction for the surrogate and intended parents. Surrogacy arrangements surrounding the birth are typically detailed as part of a surrogacy contract. However, regulation and standards are changing and current knowledge of relevant hospital and legal standards is essential to provide care for surrogate families. Everyone involved in surrogacy may need early and ongoing support, education, care options, and counseling.Remember the gestational surrogate is the patient and is always the nurses’ primary concern. When the adoptive parents have contact with the newborn is the decision of the birth mother in most situations.

Answer 10

Concerns about the consequent dehumanization of women’s birth experiences have resulted in demands for a return to continuous, one-to-one support by women for women during labor . Two complementary theoretical explanations have been offered for the effects of labor support on childbirth outcomes. Both explanations hypothesize that labor support enhances labor physiology and woman’s feelings of control and competence. First theory: During labor, women may be uniquely vulnerable to unfamiliar environmental influences; current obstetric care frequently subjects women to institutional routines, high rates of intervention, unfamiliar personnel, and lack of privacy, resulting in stress. These conditions may have an adverse effect on the progress of labor and on the development of feelings of competence and confidence; this may in turn impair adjustment to parenthood and establishment of breastfeeding and increase the risk of depression. ● This response may, to some extent, be buffered by the provision of support and companionship during labor. ● Second theory describes two pathways: enhanced passage of the fetus through the pelvis and soft tissues, and decreased stress response. ● Enhanced feto-pelvic relationships may be accomplished by encouraging mobility and effective use of gravity, supporting women to assume their preferred positions, and recommending specific positions for specific situations. ● Studies of the relationships among fear and anxiety, the stress response, and pregnancy complications have shown that anxiety during labor is associated with high levels of the stress hormone epinephrine in the blood, which may lead to abnormal fetal heart rate (FHR) patterns in labor, decreased uterine contractility, a longer active labor phase with regular well-established contractions, and low Apgar scores. ● Emotional support, information and advice, comfort measures, and advocacy may reduce anxiety and fear and associated adverse effects during labor. ● Anxiety (a sense of uneasiness in response to a vague unspecific threat) can interfere with labor and increase nausea and crying, as well as interfering with the ability to focus. Emotional factors can contribute to the experience of increased pain due to high levels of anxiety ● Fear (a painful, uneasy feeling in response to an identifiable threat) can be fear related to the unknown, fear of injury to self and fetus, or fear of pain. Fear can decrease UCs and enhance the perception of pain. Procedures and an unfamiliar environment can result in a sense of loss of control and feeling of helplessness. Women in labor can feel abandoned. Preexisting expectations and fear itself elicits a request for c-section, predisposing the woman to higher levels of pain. Nurses can help and support women to be actively involved in their own care by allowing time for discussion, listening to worries and concerns, and offering information to help women gain increased self-determination in the context of care. ● Psychosocial factors may also influence a woman’s ability to cope and anxiety levels. If she has poor coping skills and high anxiety, she may experience increased pain. Positive expectations on the part of the woman correlate to better pain relief and labor responses.

Answer 11

Discussion of the influence on labor includes a fifth “P,” maternal position during labor and birth. The woman’s position affects both anatomical and physiological adaptations to labor Position is now more accurately referred to as freedom of movement during labor, allowing the woman to labor in the position she finds most comfortable. Registered nurses are integral to this process: they suggest alternatives and support the woman in choosing positions that are most conducive to her individualized needs and tailored to her current stage and phase of labor. Walking, moving, and changing positions are all important options to facilitate freedom of movement. Resting places other than beds, such as rocking chairs and birthing balls, may be suggested. RNs provide advice, support, and encouragement to women to empower them to take advantage of the full range of options during labor. Registered nurses should be knowledgeable about positioning techniques for women with epidural analgesia, and they play a key role in supporting position changes that facilitate the birth process, promote maternal comfort, and maintain patient safety.

Answer 12

● Freedom of movement should be an option for women since it is known to enhance the ability of some women to cope with the pain of labor. Using a variety of positions makes it easier for the woman to work with her body and with the fetus as the fetus moves through the pelvis. During the first stage of labor, an upright position (walking, sitting, kneeling, or squatting) and/or a lateral position is encouraged . ● These positions are used to decrease the compression of the maternal descending aorta and ascending vena cava that could result in a compromised cardiac output. Compression of these vessels can lead to supine hypotension, resulting in decreased placental perfusion. ● The upright position has shown benefits of aiding in the descent of the infant and more effective contractions that result in shorter labor as well as decreasing the need for pain medication, oxytocin, and mechanical-assisted deliveries. Being in an upright, squatting, or side-lying position also demonstrated less severe lacerations or need for episiotomies. ● Frequent position changes are associated with a reduction of fatigue, an increase of comfort, and improved circulation to both mother and fetus. ● Maternal position in the second stage of labor can impact the natural urge to push. Upright positions provide the advantage of gravity to help the mother move the fetus through the pelvis, and gravity-neutral positions may be more relaxing. Upright positions include standing, kneeling, and squatting. Gravity-neutral positions include side-lying and hands-knees. ● During the second stage of labor, the upright position has been shown to increase the pelvic outlet and better aligns the fetus with the pelvic inlet. ● The position most used in births in the United States is the lithotomy position, which allows for provider visualization and control during the delivery process.

Answer 13

As the woman comes closer to term pregnancy, the uterus becomes more sensitive to oxytocin and the contractions increase in frequency and intensity.

Answer 14

True labor contractions occur at regular intervals and increase in frequency, duration, and intensity ● True labor contractions bring about changes in cervical effacement and dilation. ● False labor is characterized by irregular contractions with little or no cervical change.

Answer 15

Spontaneous rupture of the membranes (SROM) may occur before the onset of labor but typically occurs during labor. Once the membranes have ruptured, the protective barrier to infection is lost, and ideally the woman should deliver within 24 hours to reduce the risk of infection to herself and her fetus. Different techniques may be used to confirm rupture of membranes (ROM): ● A speculum exam may be done to assess for fluid in the vaginal vault (pooling). ● Ferning: During a sterile speculum exam, a sample of fluid in the upper vaginal area is obtained, placed on a slide, and assessed for “ferning pattern” under a microscope (Fig. 8–19A). A ferning pattern confirms ROM. ● AmniSure testing kit: The AmniSure ROM Test is a rapid, non-invasive monoclonal immunoassay that detects PAMG-1, an amniotic protein that appears in vaginal secretions if ROM has occurred. This aids clinicians with the diagnosis of ROM in pregnant women with signs and symptoms suggestive of the condition. According to published data it is ~99% accurate. ● Nitrazine paper: The paper turns blue when in contact with amniotic fluid. Can be dipped in the vaginal fluid or fluid-soaked Q-tip can be rolled over the paper (Fig. 8–19B). This method is no longer common.

Answer 16

● Assess the FHR. ● There is an increased risk of umbilical cord prolapse with ROM. ● There is a higher risk of umbilical cord prolapse when the presenting part is not engaged. ● Assess the amniotic fluid for color, amount, and odor. ● Normal amniotic fluid is clear or cloudy with a normal odor that is similar to that of ocean water or the loam of a forest floor. ● Fluid can be meconium-stained; this must be reported to the care provider as it may indicate fetal compromise in utero. ● Document the date and time of SROM, characteristic of fluid, and FHR.

Answer 17

A general rule of thumb for first-time pregnancy with no risk factors is to wait until contractions are 5 minutes apart, last 60 seconds, and are regular for at least an hour. The woman should go to the birthing center immediately when: ● The membrane ruptures, or water breaks. ● She is experiencing intense pain. ● Bloody show increases.

Answer 18

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal regulation enacted to ensure treatment for a woman seeking care in an emergency or if she thinks she is in labor, regardless of her ability to pay. Nurses who work in the labor and delivery unit(s) of the hospital need to be familiar with EMTALA regulations . In general, the criteria for admission to the hospital for labor are cervical dilation to 3 to 4 cm and/or ruptured membranes.

Answer 19

The positional changes in the presenting part required to navigate the birth canal constitute the mechanism of labor. These mechanisms are cardinal movements of labor

Answer 20

● Engagement: When the greatest diameter of the fetal head passes through the pelvic inlet; can occur late in pregnancy or early in labor

Answer 21

● Descent: Movement of the fetus through the birth canal during the first and second stages of labor

Answer 22

Flexion: When the chin of the fetus moves toward the fetal chest; occurs when the descending head meets resistance from maternal tissues; results in the smallest fetal diameter to the maternal pelvic dimensions; normally occurs early in labor.

Answer 23

● Internal rotation: When the rotation of the fetal head aligns the long axis of the fetal head with the long axis of the maternal pelvis; occurs mainly during the second stage of labor

Answer 24

Extension: Facilitated by resistance of the pelvic floor that causes the presenting part to pivot beneath the pubic symphysis and the head to be delivered; occurs during the second stage of labor

Answer 25

● External rotation/restitution: During this movement, the sagittal suture moves to a transverse diameter and the shoulders align in the anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis. Head and shoulders rotate to move under the symphysis pubis

Answer 26

● Expulsion: The anterior shoulder usually comes first followed by the remainder of the body.

Answer 27

Labor or parturition is the process in which the fetus, placenta, and membranes are expelled through the uterus. Because childbirth is a natural process, care should move forward on a continuum from noninvasive to least invasive intervention and from non-pharmacological to pharmacological interventions according to the desires of the woman and assessment of health care providers based on individual clinical situations. Because most babies are delivered in the hospital by physicians, nurses in the intrapartal setting have a key role in providing comprehensive and individualized care for women and their families. To provide this care, nurses must understand the process of labor, birth, and postpartum. By understanding the stages and phases of labor, the nurse can facilitate, assist, and provide care for the woman, the fetus, and her support systems.

Answer 28

A normal physiologic labor and birth is powered by the innate human capacity of the woman and fetus. This birth is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes. Supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for the mother and infant. The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth: 1. Labor begins on its own: Support the normal physiologic process. 2. Freedom of movement throughout labor: Allow women to move around and adapt positions of their choosing. 3. Continuous labor support from family, friends, doulas, or nursing staff. 4. Minimize interventions to allow healthy labor progress. 5. Spontaneous pushing in non-supine positions. 6. NO separation of mother and baby.

Answer 29

Labor and birth is divided into four stages ● The first stage begins with onset of labor and ends with complete cervical dilation. ● The second stage begins with complete dilation of cervix and ends with delivery of the baby. ● The third stage begins after delivery of the baby and ends with delivery of the placenta. ● The fourth stage begins after delivery of the placenta and is completed 4 hours later; it is the immediate postpartum period

Answer 30

According to data from more than 11,000 births indicates that admitting at <4cm dilated places woman at risk for increased medical interventions, epidurals, oxytocin augmentation, and cesarean sections. Early admission resulted in 84% epidural rate compared to 71% of late admissions of nulliparous women. NICU admissions and maternal breastfeeding difficulties also increased. Early admission may increase the chances of cesarean section for nulliparous woman in early labor. ACOG (2014) currently considers cervical dilation of 6 cm as the threshold for the active phase of labor. Women who are admitted to labor and delivery during the latent phase of labor are more likely to be diagnosed with slow labor progress. The diagnosis of active labor has important clinical and resource implications for the care of women in labor. Admission of women who are not in active labor is a considerable problem, leading to higher levels of medical intervention, than for those admitted in active labor.

Answer 31

The first stage of labor is defined as the progression of cervical changes. This stage is divided into three phases: latent phase, active phase, and transition. Characteristics of the first stage of labor are as follows: ● It begins with onset of true labor and ends with complete cervical dilation (10 cm) and complete effacement (100%). ● Stage 1 is the longest stage, typically lasting 12 hours for primigravidas and 8 hours for multigravidas. ● There are normally tremendous variations in lengths of labor (Cunningham et al., 2014). ● The bag of waters or fetal membranes usually ruptures during this stage. ● The woman’s cardiac output increases. ● The woman’s pulse may increase. ● Gastrointestinal motility decreases, which leads to increase in gastric emptying time (Mattson & Smith, 2011). ● The woman experiences pain associated with UCs that result in the dilation and effacement of the cervix. ● The first stage has three phases: the latent, active, and transition phases

Answer 32

Assessment during all phases of the first stage of labor includes: ● Maternal vital signs ● The woman’s response to labor and pain ● FHR and UCs ● Cervical changes ● Fetal position and descent in the pelvis

Answer 33

Nursing actions during all phases of the first stage of labor are related to ● Diet and hydration ● Once admitted to the hospital, medical orders typically limit oral intake to clear liquids. ● The WHO recommends women dictate their oral intake of carbohydrates to decrease maternal ketosis (Sharts-Hopko, 2010). ACOG endorses clear liquids during labor (2014). ● Evidence suggests there is no reason to restrict oral intake in labor although unrestricted intake in the hospital setting is rare (Singata, Tranmer, & Gyte, 2013; Tranmer, Hodnett, Hannah, & Stevens, 2005). ● Activity and rest ● Encouraging frequent position changes and upright positions assists labor progression, facilitates fetal descent, and decreases pain perception. ● Elimination ● Frequent emptying of bowel and bladder assists in comfort of the mother, provides more pelvic room as baby descends, and decreases pressure and injury to the urethra and bowel. ● Comfort ● Providing comfort measures and therapies facilitates labor progress, decreases pain perception, and supports maternal coping mechanisms to manage the labor process. ● Support and family involvement ● Shown to provide emotional and physical support to the laboring mother, decreasing stress, and possibly facilitating labor progress. ● Education ● Providing education and information about labor, procedures, and hospital policies will decrease maternal and family anxiety and fear. Empowers the women to make informed decisions. ● Safety ● Providing a safe, friendly environment will enhance the birthing experience. ● Documentation of labor admission and progression

Answer 34

In some cultures, food and drinks are consumed during labor for nourishment and comfort to help meet the demands of giving birth. Restricting fluids and foods during labor is common practice across many birth settings, with women only allowed sips of water or ice chips. Restriction of oral intake may be unpleasant for some women and may adversely influence their experience of labor. A current Cochrane Review of five research studies involving 3,130 women concluded no benefit or harm to unrestricted oral intake in labor. The authors concluded that since evidence shows no benefit or harms, there is no justification for the restriction of fluids and food in labor for women at low risk of complications (Singata et al., 2013). Nurses can engage in revision of policies to reflect current evidence and support patients’ autonomy in labor.

Answer 35

The latent phase is the early and slower part of labor with an average length of 9 hours for primiparous and 5 hours for multiparous women. Women in this phase are usually both excited and apprehensive about the start of labor. They are talkative and able to relax with the contractions. Many women choose to stay home during this phase, although some are admitted to the birth center. Indications for admittance are cervical change/ROM or fetal intolerance of labor. Most can go home to a more relaxed setting at this stage and return to the birth center when labor progresses. Awaiting admission until active labor decreases the need for medical interventions and facilitates fetal descent and labor support of the family to the patient. However, a recent Cochrane Review concluded additional assessment and enhanced support in early labor compared to traditional care showed that these enhanced interventions may reduce the use of epidural, prevent the need to augment labor with oxytocin, and increase maternal satisfaction Characteristics of this phase are: ● Cervical dilation from 0 to 4 cm with effacement from 0% to 40%. ● Mild intensity contractions occur every 5 to 10 minutes, lasting 30 to 45 seconds. Women often describe them as feeling like strong menstrual cramps.

Answer 36

● Laboratory tests, which may include complete blood count (CBC), urinalysis, and possible drug screening. ● Order IV or saline lock. ● Order intermittent fetal monitoring or continuous fetal and uterine monitoring.

Answer 37

Nonpharmacological Strategies for Nurses and Comfort Measures in Labor Labor support is a repertoire of techniques used to help women with the process of childbirth (Wood & Carr, 2003). Providing support and comfort is one of the primary activities of nurses and includes: Emotional Support • Sustaining physical presence, eye contact • Verbal encouragement, reassurance, and praise • Listening to woman and family • Distraction Physical Support • Comfort measures such as ice chips, fluids, food, and pain medications • Hygiene including mouth care, pericare, and changing soiled linens • Assistance with position changes and ambulation • Reassuring touch, massage • Application of heat and cold • Hydrotherapy in shower and tub. Hydrotherapy is safe and effective as a complementary pain management therapy • Calm environment (dim lighting, quiet, music, minimize interruptions) Informational Support • Provide information on the progress of labor. • Explain all procedures. • Communicate in lay language so the woman and her family understand. • Offer advice. • Use interpreters as needed. Advocacy • Support decisions made by the woman and her family. • Ensure respect for the woman’s decisions. • Manage the environment, which includes visitors. • Translate the woman’s wishes to others. • Offer advice. Support of the Partner and Family • Offer support and praise. • Role model therapeutic behaviors. • Assist the partner with food and rest. • Provide breaks if desired or needed.

Answer 38

● Admit to the labor unit and orient the woman, her partner, and family to the labor room. ● The review of the prenatal record will give information from pregnancy onset to the present. The prenatal record should include all lab tests and ultrasounds (for estimated date of delivery (EDD) and placental location) as well as any prior obstetrical history (pregnancy, births, abortions, and living children). A review of allergies and medications, trends in vital signs and weight gain, chronic conditions, or pregnancy-related complications will also be a part of the record. Biochemical and infectious disease laboratory test results; for example, Group B streptococcus (GBS) status, are also included. ● Complete labor and delivery admission record (Fig. 8–22). ● Review childbirth plan and discuss the woman’s expectations. ● Woman may present with a birth plan: Some providers and childbirth educators encourage the family to think about how they “see” the labor and birth process. It is a wish list that allows the woman to express her wishes and preferences and communicate with care providers during her prenatal appointments. This discussion should include hospital policies and medical interventions. Review this plan with the woman during the admission process and clarify what you can and cannot provide. This will facilitate open communication and show respect for her expectations. ● Teach and reinforce relaxation and breathing techniques. ● Support what they have been practicing or teach techniques as needed to decrease pain and anxiety. ● Obtain laboratory tests as per orders. ● Provides information on patient status and health. ● Start IV or insert saline lock, if ordered. ● Provides access for fluids and or medications if needed. ● Review the woman’s report of onset of labor. ● Assess and record the following (see Fig. 8–22 and Clinical Pathway and Concept Map): ● Maternal vital signs ● FHR ● Uterine contractions ● Cervical dilation and effacement; and fetal presentation, position, and station by performing a sterile vaginal examination (SVE) (Fig. 8–24, Box 8–2). ● Status of membranes ● Amniotic fluid for color, amount, consistency, and odor ● Vaginal bleeding or bloody show for amount and characteristics of vaginal discharge ● Fetal position with Leopold maneuver (Fig. 8–25, Box 8–3) ● Deep tendon reflexes ● Signs of edema ● Heart and lung sounds ● Emotional status ● Pain and discomfort ● Review laboratory results, note blood Rh status hematocrit and hemoglobin and dipstick urine for glucose and protein or send urine specimen to the lab for analysis. ● Document allergies, history of illness, and last food intake. ● Encourage fluid intake; food may or may not be restricted. ● Provide comfort measures. ● Encourage the woman to walk as much as possible by: ● Explaining the importance of walking in facilitating labor progression and fetal descent and rotation and in making UCs more efficient ● Walking with the woman, which can provide a comforting and reassuring presence and distraction ● Assess cultural needs and incorporate beliefs in the nursing care and delivery plan. ● Establish a therapeutic relationship through active listening and providing labor support (Box 8–4). ● Incorporate understanding of the couple’s maturity level, educational level, and previous experience into nursing care. ● Review the labor plan with the woman and her partner. ● Inquire about concerns and questions the woman and/or her partner have concerning the labor and birth process. ● Provide clear explanations and updates on progress. ● These nursing actions will provide information to the nurse to facilitate teaching moments, decrease patient anxiety, and support the plan of care.

Answer 39

Sterile Vaginal Exam Intrapartal Sterile Vaginal Exam To perform a vaginal exam, the labia are separated with a sterile gloved hand. Fingers are lubricated with a water-soluble lubricant. The first and second fingers are inserted into the introitus; the cervix is located and the following parameters are assessed (Fig. 8–24): ● Cervical dilation: This measurement estimates the dilation of the cervical opening by sweeping the examining finger from the margin of the cervical opening on one side to that on the other. ● Cervical effacement: This measurement estimates the shortening of the cervix from 2 cm to paper-thin measured by palpation of cervical length with the fingertips. The degree of cervical effacement is expressed in terms of the length of the cervical canal compared to that of an unaffected cervix. When it is reduced by one-half (1 cm), it is 50% effaced. When the cervix is thinned out completely, it is 100% effaced. ● Position of cervix: Relationship of the cervical os to the fetal head and is characterized as posterior, midposition, or anterior. ● Station: Level of the presenting part in the birth canal in relationship to the ischial spines. Station is 0 when the presenting part is at the ischial spines or engaged in the pelvis. ● Presentation: Cephalic (head first), breech (pelvis first), shoulder (shoulder first) ● Fetal position: Locate presenting part and specific fetal structure to determine fetal position in relation to the maternal pelvis.

Answer 40

The purpose of Leopold’s maneuvers is to inspect and palpate the maternal abdomen to determine fetal position, station, and size (Fig. 8–25). ● The first maneuver is to determine what part of the fetus is located in the fundus of the uterus. ● The second maneuver is to determine location of the fetal back. ● The third maneuver is to determine the presenting part. ● The fourth maneuver is to determine the location of the cephalic prominence.

Answer 41

● Review GBS status, if GBS positive intrapartum IV antibiotic prophylaxis is given. ● Group B streptococci (GBS), also known as Streptococcus agalactiae, can cause perinatal morbidity and mortality. Between 10% and 30% of pregnant women are colonized with GBS in the vagina or rectum. Implementation of national guidelines for intrapartum antibiotic prophylaxis since the 1990s has resulted in an approximate 80% reduction in the incidence of early-onset neonatal sepsis due to GBS. Vertical transmission of GBS during labor or delivery may result in invasive infection in the newborn during the first week of life. Penicillin remains the drug of choice, with ampicillin as an alternative. ● Intrapartum GBS prophylaxis (CDC, 2010) is indicated: ● Previous infant with invasive GBS disease ● GBS bacteria during any trimester of current pregnancy ● Positive GBS vaginal-rectal screening culture in late gestation during current pregnancy ● Unknown GBS status at onset of labor with <37 weeks gestation, or ROM >18 hours, or temperature > 100.4°F or >38.0°C

Answer 42

recommendations for health care providers and administrators: * Ensure that patient-centered care and patient safety are organizational priorities that guide decisions for policies and practices. * Foster a culture of openness by promoting the active communication of good outcomes and opportunities for improvement. * Develop forums to facilitate communication and track issues of concern. * Provide resources for clinicians to be trained in the principles of teamwork, safety, and shared decision making. * Develop methods to systematically track and evaluate care processes and outcomes. * Facilitate cross-departmental sharing of resources and expertise. * Ensure that quality obstetric care is a priority that guides individual and team decisions. * Identify and communicate safety concerns and work together to mitigate potential safety risks. * Disseminate and use the best available evidence, including individual and hospital-level data, to guide practice patterns. The joint call to action underscores the collective belief among health care providers that ongoing collaboration is a key element to improving health care outcomes. By providing interprofessional collaboration and care management for families in labor, the overall experience can promote optimal patient care, satisfaction, and maternal and fetal outcomes.

Answer 43

The active phase (dilation to 7 cm) of labor averages three to six hours. It is typically shorter for multigravidas Women in this phase may have decreased energy and experience fatigue. They become more serious and turn attention to internal sensations. As labor progresses, most women turn inward. Characteristics of this phase include the following: ● The consortium on safe labor reviewed more than 19,000 births and determined that nulliparous and parous woman dilate at a similar rate between 4-6 cm, much slower than Friedman (1955) determined in the 1950s: “6 is the new 4” (Zhang et al., 2010). The older standard was cervical dilation progression from 4 cm to 7 cm with effacement of 40% to 80%. ● Fetal descent continues. ● Contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. ● Discomfort increases; this is typically when the woman comes to the birth center or hospital if she has not done so already.

Answer 44

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) asserts that continuously available labor support from a registered nurse (RN) is a critical component to achieve improved birth outcomes. The RN assesses, develops, implements and evaluates an individualized plan of care based on each woman’s physical, psychological and socio-cultural needs, including the woman’s desires for and expectations of the laboring process. The support provided by the RN should include the following: ● Assessment and management of the physiological and psychological processes of labor ● Facilitation of normal physiologic processes, such as the women’s desire for movement in labor ● Provision of emotional support and physical comfort measures, informational support, and advocacy ● Evaluation of fetal well-being during labor ● Instruction regarding the labor process ● Patient advocacy and collaboration among members of the health care team ● Role modeling to facilitate family participation during labor and birth ● Direct collaboration with other members of the health care team to coordinate patient care

Answer 45

.ACOG currently defines the active phase of labor as cervical dilation of 6 cm as the threshold for the active phase of most women in labor. Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied (ACOG, 2014). Recently, several professional organizations have come out in support of physiologic birth practices and the reduction in the number of unnecessary interventions during birth (ACOG, 2014; AWHONN, 2014b), increasing recognition of the benefits of physiologic birth and the risks of medical interventions during labor and birth and increasing focus on avoiding unnecessary interventions during labor. Although interventions are sometimes necessary and not always detrimental, they can lead to interruption in normal physiologic labor and may result in further interventions that do not improve health outcomes (Zielinski et al., 2016). Redefining active labor to 6 cm dilation can assist in identifying when delays in labor are appropriately identified based on this new classification and avoid the use of interventions guiding the latent phase of labor before labor is well-established.

Answer 46

● Rupture membranes if not previously ruptured, if indicated. ● Evaluate fetal status by fetal monitoring as indicated, either intermittent or continuous. ● Perform internal monitoring with application of internal fetal electrode and/or uterine transducer, if necessary. ● Pain assessment: Order pain medication or epidural anesthesia. ● Evaluate progression in labor.

Answer 47

● Monitor FHR and contractions every 15 to 30 minutes. ● Monitor maternal vital signs every 2 hours; every 1 hour if ROM. ● Perform intrapartal vaginal exam as needed to assess cervical changes and fetal descent (see Box 8–2). ● Assess pain (location and degree). ● Administer analgesia as per orders and desire of woman. ● Evaluate effectiveness of epidural or other pain medication. ● Monitor intake and output (I&O), hydration status, and for nausea and vomiting. ● Offer oral fluids as per orders (ice chips, popsicles, carbohydrate liquids, and water). Encourage the woman to listen to her body regarding hydration and nausea and allow her to decide when she has had enough intake. ● Offer clear explanations and updates of progress. ● Promote comfort measures. ● Assist with elimination (bladder distension can hinder fetal descent). ● Encourage breathing and relaxation methods (see Box 8–4). ● Review and reinforce relaxation techniques. ● Maintain eye contact and physical proximity to the woman. ● Develop a rhythm and breathing style to deal with each contraction. ● Use a direct and gentle voice and have a calm and confident manner. ● Use touch or massage if acceptable to the woman. ● Interdisciplinary collaboration management of labor assists in communicating the woman’s progress and status with other care providers. ● Incorporate the support person in care of patient by: ● Role modeling supportive behaviors ● Offering support and praise ● Assisting partner with food and rest ● Providing breaks if desired or needed ● Explain procedures before initiating, asking permission from the patient. ● Assess the environment for adjustments to be made; typically decrease stimulation with dim lighting and decrease noise and interruptions. ● Provide reassurance, updates on progress, and positive reinforcement.

Answer 48

The transition phase (dilation to 10 cm), is usually the most difficult but shortest of the first stages of labor (see Table 8–1). In transition, women are easily discouraged and irritable, and may be overwhelmed and panicky. They often feel and act out of control. Characteristics of this phase are: ● Cervical dilation from 8 to 10 cm with complete (100%) effacement ● Intense contractions every 1 to 2 minutes lasting 60 to 90 seconds ● Exhaustion and increased difficulty concentrating ● Increase of bloody show ● Nausea and vomiting ● Backache: Woman complains of back pressure, hand goes over hip, rubbing and pressing on area. ● Trembling ● Diaphoresis, especially upper lip and facial area ● May have a strong urge to bear down or push, more vocal with primal noises and facial expressions.

Answer 49

● Perform amniotomy (AROM) if not previously done. ● Assess fetal position and cervix. ● Prepare for delivery.

Answer 50

● Assess FHR and UCs every 15 minutes. ● Provide calming support and reassurance, speaking slowly in low, soothing tone, giving short and clear directs such as: “You are in control;” “It is normal to feel so much pressure as the baby moves down;” “You are doing a great job working with your contractions.” ● Woman who are given encouragement and empowered to follow their body will have less anxiety and fear of the process and will perform with more control and conviction. ● Encourage the woman to breathe during contractions and rest between contractions by staying with patient and breathing with her (see Box 8–4). Assist with breathing and relaxation methods by demonstrating breathing through demonstration and reinforcement. ● Providing support and encouragement will assist in decreasing fear and anxiety. ● Assess I&O and assist with toileting as needed. ● Bladder distension may hinder fetal descent, cause bladder trauma and discomfort. ● Promote comfort measures. ● Attend to the woman’s hygiene needs, such as mopping her brow and face, providing pericare, and changing chux. ● Providing comfort and hygiene measures shows attention to and respect for the patient’s personal needs. ● Prepare the room and couple for delivery. ● Familiarize the woman and support people with usual routine and keep them informed of what to expect. ● Open the delivery tray. ● Turn on the infant radiant warmer. ● Use brief explanations, as the woman’s focus is narrowed. ● Remain in the room with the woman and family. ● Provide encouragement and reassurance to the woman and her support person(s). ● Keep them apprised of labor progress, such as changes in cervical dilation. ● Compliment them on their effective breathing and relaxation techniques.

Answer 51

The woman enters the second stage of labor when cervical dilation is complete (10 cm) (see Table 8–1). This stage ends with the birth of the baby (Fig. 8–26). Women in the second stage may have a burst of energy, be more focused, and feel like they can actively participate in facilitating birth with active pushing efforts. Phases of the second stage of labor are as follows: ● Latent or resting phase is characterized by a period of rest and relative calm. The urge to bear down is usually not well-established, particularly for women with regional analgesia/anesthesia. The fetus can passively descend in the pelvis during this time without maternal expulsive efforts. ● Descent or active phase is characterized by increasing intensity of uterine contractions and strong urges to bear down with the activation of Ferguson’s reflex. During this phase, bearing-down efforts are most effective for promoting birth. ● Physiologic processes of the second stage of labor are the normal bodily function by which the fetus traverses the pelvic outlet and is expelled from the uterus through the force of strong uterine contractions, voluntary and involuntary bearing down, and stretching of the soft tissues of the female reproductive tract. The process involves numerous hemodynamic changes that may affect the reproductive, cardiac, respiratory, gastrointestinal, and renal systems. Changes in maternal physiology during the second stage of labor may also be influenced by maternal position and energy level, pain, and hydration. Characteristics of this stage include the following: ● Typically lasts 50 minutes for primigravidas and 20 minutes for multigravidas, although a second stage of several hours is normal. ● Woman may feel an intense urge to push or bear down when the baby reaches the pelvic floor. ● Studies have shown that bearing down in the second stage is less tiring and more effective when started after the woman has the urge to do so rather than before. Nulliparous women with epidurals who delayed their efforts until feeling the urge to push (Ferguson’s reflex) had 27% shorter pushing time. This decreased maternal fatigue, provided increased maternal satisfaction in the birth experience, and allowed women to fully participate in postpartum activities ● Contractions are intense, occurring every 2 minutes and lasting 60 to 90 seconds. ● Bloody show increases. ● The perineum flattens and the rectum and vagina bulge. Although it was once thought that limiting the second stage of labor to 2 hours was essential to decrease the risks of fetal morbidity and mortality, we now know that waiting more than 2 hours for the fetus to descend spontaneously is usually safe for the fetus. As long as the fetal heart rate (FHR) is reassuring and evidence shows fetal descent, waiting a reasonable time for spontaneous birth usually poses no risk to the fetus. Current data suggest a prolonged second stage beyond 4 hours may increase maternal risk of operative vaginal birth and perineal trauma

Answer 52

Although women who use spontaneous pushing techniques may have a slightly longer second stage, the benefits of such pushing are well-documented. However, some nurses, midwives, and physicians continue to instruct patients to “take a deep breath, hold it, and push.” Pushing techniques (AWHONN, 2008) include the following:(next few cards) To maximize pushing efforts, the nurse should assess the woman’s knowledge of pushing techniques, expectations for pushing, presence of Ferguson’s reflex, intensity of uterine contractions, readiness to push, and the fetal presentation, position, and station. With adequate information, the woman can actively participate in the decision to start pushing. When pushing begins, women should be encouraged to push for 6 to 8 seconds, followed by a slight exhale, and repeat this pattern for three to four pushes per contraction or as tolerated by the woman and her fetus.

Answer 53

● Closed glottis (involuntary) refers to spontaneous pushing against a closed glottis (Valsalva) in response to the descent of the fetal presenting part on the perineum.

Answer 54

● Closed glottis (voluntary), also referred to as the Valsalva technique, involves a voluntary directed strenuous bearing-down effort against a closed glottis for at least 10 seconds. The woman is instructed to take a deep breath and hold it for as long as she can (during each count of 10) using the entire contraction. This method usually involves two to three pushes of 10 seconds each with each contraction

Answer 55

● Directed pushing refers to instructions from care providers to the woman concerning how to push and often includes directions to “hold your breath” (closed glottis or Valsalva technique) to a count of 10 or more seconds. Instructions also may be given concerning positioning during pushing; often a supine or semi-Fowler’s position is advised rather than encouraging the woman to choose her own position of comfort.

Answer 56

● Nondirected pushing refers to care providers encouraging the woman to choose whatever method she feels is effective to push her baby out, including choosing the position during pushing, deciding whether to hold her breath during pushing efforts, and determining the duration of each pushing effort.

Answer 57

● Open glottis refers to spontaneous, involuntary bearing-down accompanying the forces of the uterine contraction and is usually characterized by expiratory grunting or vocalizations. The spontaneous method usually involves three to four pushes of 6 to 8 seconds with each contraction.

Answer 58

Measures proposed to enhance perineal stretching and decrease perineal trauma include the application of warm compresses, gentle perineal massage and stretching, and perineal massage with warm oil during the second stage of labor. No evidence from any randomized clinical trial published to date confirms that use of warm compresses or second-stage perineal massage with or without oil decreases the need for episiotomy or the risk of perineal trauma

Answer 59

● Assess the woman’s knowledge of pushing techniques, expectations for pushing, presence of Ferguson’s reflex (urge to bear down), and readiness to push as well as the fetal presentation, position, and station. ● Pushing techniques may vary. Pushing efforts may be directed or nondirected, but nondirected pushing is preferable. Women should be permitted to choose whether to hold their breath while pushing (closed- vs. open-glottis pushing). ● When pushing begins, women should be encouraged to push for 6 to 8 seconds, followed by a slight exhale, and repeat this pattern for three to four pushes per contraction or as tolerated by the woman and her fetus. ● Woman can be encouraged to bear down and hold it as long as she can or “do whatever comes naturally” when conditions are physiologically appropriate for active pushing. ● Whenever possible, discourage the traditional practice of breath holding for 10 seconds with each contraction. Closed glottis pushing, also referred to as the Valsalva technique, involves a voluntary or directed strenuous bearing-down effort against a closed glottis for at least 10 seconds. This method usually involves two to three pushes of 10 seconds each during a contraction. ● Provide birthing aids such as birthing balls, squat bars, birthing stools, and cushions to support the woman and the pelvis. ● Evaluate the effectiveness of pushing efforts and descent of the presenting part. ● Support and facilitate the woman’s spontaneous pushing efforts. ● Evaluate the effectiveness of upright or other positions on fetal descent, rotation, and maternal-fetal condition. ● Upright positioning for the second stage of labor refers to the patient’s position sitting with the head of the bed at a 45-degree angle or greater, squatting, kneeling, or standing during the second stage of labor. A woman may use birthing aids such as birthing balls and squatting bars to help maintain her position. Benefits of upright positioning include possible increase of pelvic diameter by 30%, shortened duration of second stage, decreased pain, and decreased perineal trauma. ● A recent Cochrane Review suggests several possible benefits for upright posture in women without epidural anesthesia, such as a reduction in the duration of second stage of labor and reduction in episiotomy rates and assisted deliveries. However, there is an increased risk of blood loss greater than 500 mL and there may be an increased risk of second degree tears (Gupta et al., 2017). ● Ferguson’s reflex is a physiological response of the woman, activated when the presenting part of the fetus is at least at+1 station; it is usually accompanied by spontaneous bearing-down efforts. Pushing efforts may be delayed until the Ferguson reflex is present. ● Delayed pushing is waiting for fetal descent and or initiation of Ferguson’s reflex before pushing begins in the second stage of labor. Delayed pushing is also referred to as “laboring down,” “passive descent,” and “rest and descend.” ● Delayed pushing may also be appropriate for women with epidural anesthesia/analgesia who do not feel the urge to push.

Answer 60

● Prepare for delivery. ● Provide reassurance to the woman while she pushes and brings baby down through the birth canal. ● Support fetal head and maternal perineum to avoid performing episiotomy (Box 8–5). ● Assist the woman in birthing her child.

Answer 61

● Instruct the woman to bear down with the urge to push. ● More progress is made and fewer traumas are noted to mother and fetus with spontaneous pushing efforts. ● Monitor for fetal response to pushing; check FHR every 5 to 15 minutes or after each contraction. ● Assess fetal heart rate response to pushing efforts. ● Explain the need for vaginal examinations and the pressure and/or pain sensations anticipated. Negotiate when exams will be performed whenever possible. Perform vaginal examinations only as needed, share findings with the woman and her partner, and acknowledge and apologize for the discomfort caused during these procedures ● Provide comfort measures and allow woman to be in position of comfort. ● Provide reassurance, empathy, and encouragement to the woman by methods such as acknowledging the stress and work of labor, acknowledging unpleasant sensations, and encouraging woman’s spontaneous pushing efforts. ● Attend to perineal hygiene as needed, as the woman may pass stool with pushing. ● Provides a cleaner pathway. ● Validate and explain the physical sensations experienced by the woman during the second stage of labor. Give praise and encouragement of progress made. ● Encourage rest between contractions by breathing with the patient and therapeutic touch. ● Decreases fatigue and hypoxia in fetus by providing increased oxygenation. ● Review and reinforce pushing technique by: ● Maintaining eye contact. ● Developing a rhythm and pushing style to deal with each contraction that maximizes the woman’s urge to push. ● Using direct, simple, and focused communication, avoiding unnecessary conversation. ● Advocate on the woman’s behalf for her desires of the delivery plan. Facilitate collaboration or negotiation among other caregivers on behalf of the woman to support care decisions and preferences whenever possible. ● Evaluate the father’s, partner’s, or labor coach’s knowledge of physical, emotional, and psychosocial support needed during labor and augment as needed to meet the individual woman’s need. ● Assist the support person and partner. ● Role model supportive behaviors. ● Offer support, praise, and encouragement. ● Assist with food and rest and provide breaks.

Answer 62

Episiotomy is an incision in the perineum to provide more space for the presenting part at delivery (see Fig. 8–27). Routine use of episiotomy at delivery is no longer typical. A median or midline episiotomy is at the midline and tends to heal more quickly with less discomfort. A medilateral episiotomy is cut at a 45-degree angle to the left or right and may be used for a large infant. It tends to heal more slowly, causes greater blood loss, and is more painful. Lacerations are tears in the perineum that may occur at delivery (see Fig. 8–28). ● Lacerations can occur in the cervix, vagina, and/or the perineum (see Fig. 8–30A). ● A first-degree laceration involves the perineal skin and vaginal mucous membrane (see Fig. 8–30B). ● A second-degree laceration involves skin, mucous membrane, and fascia of the perineal body (see Fig. 8–30C). ● A third-degree laceration involves skin, mucous membrane, and muscle of the perineal body and extends to the rectal sphincter (see Fig. 8–30D). ● A fourth-degree laceration extends into the rectal mucosa and exposes the lumen of the rectum (see Fig. 8–30E).

Answer 63

The third stage of labor begins immediately after the delivery of the fetus and involves separation and expulsion of the placenta and membranes (see Table 8–1). As the infant is born, the uterus spontaneously contracts around its diminishing contents. This sudden decrease in uterine size is accompanied by a decrease around placental implantation. This results in the decidual layer separating from the uterine wall. Placental separation typically occurs within a few minutes to less than a half hour after delivery. Once the placenta separates from the wall of the uterus, the uterus continues to contract until the placenta is expelled (Fig. 8–27). This process typically takes 5 to 30 minutes post-delivery of the baby and occurs spontaneously. Signs that signify the impending delivery of the placenta include: ● Upward rising of the uterus into a ball shape ● Lengthening of the umbilical cord at the introitus ● Sudden gush of blood from the vagina Active management of the third stage of labor (AMTSL) includes uterotonic drugs (oxytocin is the gold standard), controlled cord traction, and late cord clamping performed 1-3 minutes after delivery. These interventions decrease postpartum hemorrhage (PPH) and cause uterine contractions and placenta expulsion (AWHONN, 2014a). The placenta, membranes, and cord are examined by the care provider for completeness and anomalies.

Answer 64

Normal blood loss for a vaginal birth is approximately 500 ml within 24 hours. Visual estimation of blood loss (EBL) is common practice in obstetrics; however, the inaccuracy of EBL has been well-established and blood loss can be underestimated by up to 50%. AWHONN recommends that cumulative blood loss be formally measured or quantified after every birth. Inaccurate measurement of postpartum blood loss has the following implications: * Underestimation can lead to delay in delivering lifesaving hemorrhage interventions. * Overestimation can lead to costly, invasive, and unnecessary treatments such as blood transfusions that expose women to unnecessary risks. Direct measurement of blood loss can be accomplished by two complementary approaches. The easiest to initiate is to collect blood in calibrated, under-buttocks drapes for vaginal birth. The second approach is to weigh blood-soaked items and clots. These items can be collected in a single bag and weighed using a gravimetric method. By using this method, the weight of dry pads is subtracted from the total weight to obtain an estimate of blood loss. Weigh all blood-soaked materials and clots to determine cumulative volume

Answer 65

Uterotonics The use of uterotonics for the prevention of PPH during the third stage of labor is recommended for all births (WHO, 2012). Oxytocin is the recommended uterotonic drug for the prevention of PPH. Oxytocin should be used for management of third stage of labor for all births

Answer 66

● Classification: hormone/oxytocic ● Route: Oxytocin should be administered only by the intramuscular (IM) or intravenous (IV) route, not by IV push. As a high-alert medication, IV oxytocin pre-mixed bags should be: ● Infused via an IV infusion pump to control oxytocin administration ● Prominently and clearly labeled with bright-colored labeling ● Stored separately to prevent a 1000 milliliter IV bag with oxytocin being mistaken for a plain 1000 milliliter bag used for IV fluid resuscitation bolus ● Administer IV oxytocin by providing a bolus dose followed by a total minimum infusion time of 4 hours after birth, or per hospital policy. For women at high risk for a postpartum hemorrhage, continuation beyond 4 hours is recommended. Rate and duration should be titrated according to uterine tone and bleeding. ● Common dosing is oxytocin 20 units in 1-liter normal saline (NS) or lactated Ringer’s (LR) solution with an initial bolus rate 1000 ml/hour bolus for 30 minutes (equals 10 units) followed by a maintenance rate 125 ml/hour over 3.5 hours (equals remaining 10 units). ● Give oxytocin 10 units IM in women without IV access. ● Actions: Stimulates uterine smooth muscle that produces intermittent contractions. Has vasopressor and antidiuretic properties. ● Indications: Control of PP (postpartum) bleeding after placental expulsion.

Answer 67

● Classification: Oxytocic/ergot alkaloids ● Route/Dosage: PO 200–400 mcg (0.4–0.6 mg) every 6 to 12 hours for 2 to 7 days. IM 200 mcg (0.2 mg) every 2 to 4 hours up to 5 doses. IV (for emergencies only) same dosage as IM. ● Actions: Directly stimulates smooth and vascular smooth muscles causing sustained uterine contractions. ● Indications: Prevent or treat PP hemorrhage/uterine atony/subinvolution. Contraindicated in hypertensive patients.

Answer 68

● Classification: Prostaglandin ● Route/Dosage: IM 250 mcg injected into a large muscle or the uterus. ● Actions: Contraction of uterine muscle ● Indications: Uterine atony

Answer 69

● Classification: antiulcer/prostaglandins ● Route/Dosage: PO/Rectally 200–1,000 mcg ● Actions: Acts as a prostaglandin analogue causes uterine contractions. ● Indications: To control PP hemorrhage. This medication is used off-label and is not yet approved by the FDA for this use.

Answer 70

● At delivery, the neonate is often placed skin-to-skin on mother’s chest. ● Await delivery of the placenta, typically within 20 minutes of delivery. ● If the third stage of labor lasts more than 30 minutes, IV/IM oxytocin (10 IU) may be used to manage the retained placenta. If the placenta is retained and bleeding occurs, the manual removal of the placenta should be expedited. Whenever the manual removal of the placenta is undertaken, a single dose of prophylactic antibiotics is recommended (WHO, 2012). ● Inspect the placenta after delivery: Intact, three-vessel cord, cord attachment to placenta. ● Order pain medications and uterotonics if necessary.

Answer 71

● Administer uterotonic per protocol after delivery of the placenta. ● Assess maternal vital signs every 15 minutes. ● Encourage the woman to breathe with contractions and relax between contractions. ● Encourage mother-baby interactions by providing immediate newborn contact, if the newborn is stable. ● Administer pain medications as per order. ● Complete documentation of the delivery (Fig. 8–28). ● Documentation of delivery includes labor summary, delivery summary for mother and baby, infant information, infant resuscitation, and documentation of personnel in attendance. ● Explain all forthcoming procedures. ● Stay with the woman and her family.

Answer 72

The fourth stage begins after delivery of the placenta and typically ends within 4 hours or with the stabilization of the mother. After the placenta delivers, the primary mechanism by which hemostasis is achieved at the placental site is vasoconstriction produced by a well-contracted myometrium. During this stage, the nurse is caring for both the woman and her newborn child (see Table 8–1). This stage also begins the postpartum period .

Answer 73

An important goal during the fourth stage is the newborn-family attachment. This is promoted by allowing early contact with the newborn and encouragement of eye contact and touch. The baby is placed skin-to-skin on the mother and covered with a warm blanket. Positive maternal bonding behaviors include making eye contact, touching and talking to the baby, smiling and cuddling the newborn, and similar actions. This is often the best time to institute breastfeeding. The newborn may remain in the labor and delivery room with the family for the immediate recovery period.

Answer 74

● Repair the episiotomy or laceration ● Inspect the placenta. ● Assess the fundus for firmness. ● Order uterotonics. ● Order pain medications, if necessary.

Answer 75

● Explain all procedures. ● Assess the uterus for position, tone, and location, intervening with fundal massage as necessary. ● Assess lochia for color, amount, and clots. May weigh initial blood loss on scale to estimate EBL (1 gm = 1 cc) to provide for a more accurate evaluation of blood loss (AWHONN, 2014c). ● Administer medications as per orders. ● Assist the care provider with repair of lacerations and/or episiotomy. ● Assess maternal vital signs every 15 minutes. ● Monitor perineum for unusual swelling or hematoma formation. ● Apply ice packs to the perineum. ● Monitor for bladder distention. ● Assist the woman to the bathroom and measure void. ● Assess for return of full motor-sensory function if epidural or spinal anesthesia is used. ● Assess pain and medicate as per orders. ● Stay with the mother and family. ● Offer congratulations and reassurance on a job well done to the woman and family. ● Explore with the family any requests they have for keeping the placenta. Some cultures consider the placenta part of the woman’s body and there are a variety of rituals associated with disposal of the placenta. Efforts should be made to accommodate those requests (Callister, 2014). ● Encourage mother-baby interaction by: ● Providing immediate newborn contact ● Assisting with early breastfeeding, if desired ● Pointing out the newborn’s quiet, alert state ● Monitor newborn status, including temperature, heart and respiratory rates, skin color, adequacy of peripheral circulation, type of respiration, level of consciousness, and tone and activity every 30 minutes. ● Provide an opportunity for the support person to interact with newborn

Answer 76

Newborn transition and initial care typically occur in the labor and delivery room. Initial assessments can be safely done with the infant skin-to-skin on the mother’s abdomen after delivery, if the infant is stable. Researchers demonstrated that newborns have better outcomes, including stable temperature, heart rate, respiratory rate, and glucose levels, when they transition to extrauterine life and establish immediate skin-to-skin contact with their mothers

Answer 77

Apgar scores should be obtained at 1 minute and 5 minutes after birth. If the 5-minute Apgar score is less than 7, additional scores should be assigned every 5 minutes up to 20 minutes. Temperature, heart and respiratory rates, skin color, adequacy of peripheral circulation, type of respiration, level of consciousness, tone, and activity should be monitored and recorded at least every 30 minutes until the newborn’s condition has remained stable for at least 2 hours. The Apgar score is a rapid assessment of five physiological signs that indicate the physiological status of the newborn and includes ● Heart rate based on auscultation ● Respiratory rate based on observed movement of chest ● Muscle tone based on degree of flexion and movement of extremities ● Reflex irritability based on response to tactile stimulation ● Color based on observation Each component is given a score of 0, 1, or 2. An Apgar score of: ● 0 to 3 indicates severe distress ● 4 to 6 indicates moderate difficulty with transition to extrauterine life ● 7 to 10 indicates stable status. The Apgar score is not used to determine the need for resuscitation, nor is it predictive of long-term neurological outcome of the neonate . Rather it is a rapid, objective, convenient shorthand for reporting the status of the newborn and the response to resuscitation immediately after birth.

Answer 78

At every delivery, one person should be solely responsible for assessment of the neonate response to the birth and have the capacity to initiate resuscitation of the neonate if needed. The initial steps of resuscitation are to provide warmth by placing the baby under a radiant heat source, positioning the head in a “sniffing” position to open the airway, clearing the airway if necessary with a bulb syringe or suction catheter, drying the baby, and stimulating breathing. Further discussion of neonatal resuscitation is beyond the scope of this book except to mention optimal management of oxygen during neonatal resuscitation becomes particularly important because of the evidence that either insufficient or excessive oxygenation can be harmful to the newborn infant.

Answer 79

AWHONN (2014d) is currently focused on initiatives to increase the percentage of healthy, term newborns of stable mothers who receive uninterrupted skin-to-skin contact for at least 60 minutes. All routine procedures and assessments should be performed while the newborn is skin-to-skin with the mother. Procedures that require separation of the mother and infant, such as bathing and weighing, should be delayed until after the initial period of skin-to-skin contact. Skin-to-skin contact is described as holding the unclothed, diapered newborn on the mother’s or caretaker’s bare chest, usually in an upright position. Skin-to-skin contact is also referred to as kangaroo care. The following recommendations for full-term, healthy newborns represent the consensus of the AWHONN Power of Touch Scientific Advisory Panel. ● All stable infants greater than 37 weeks and 0 days gestation born by vaginal or cesarean birth should be placed in immediate skin-to-skin contact for at least the first hour of life or until the first breastfeeding is completed. ● All mothers of stable infants greater than 37 weeks and 0 days gestation should be offered the option of skin-to-skin contact during painful neonatal procedures, such as vaccinations and blood sampling, whenever possible. ● All parents of healthy infants greater than 37 weeks and 0 days gestation should be encouraged to have frequent, uninterrupted skin-to-skin contact with their newborns while in the hospital and after discharge. ● Uninterrupted skin-to-skin contact should be encouraged for at least the first hour of life after birth and until the first breastfeeding is completed as long as the mother and newborn remain stable. If desired, skin-to-skin contact can be extended to the first two to three hours of life if the mother and infant remain stable. Routine care practices should ideally be delayed until the initial skin-to-skin session is completed.

Answer 80

One of the first procedures after birth is newborn identification. Perinatal nurses must be meticulous when recording the identification band number and birth and newborn information and applying identification bands to mothers and newborns. Institutional policies for newborn identification and newborn safety may vary. Three medications are routinely administered to newborns: ● Erythromycin ointment is administered to the eyes as prophylaxis to prevent gonococcal and Chlamydia infections. ● Vitamin K is administered via intramuscular injection to prevent hemorrhagic disease caused by vitamin K deficiency. ● Hepatitis B virus vaccine is recommended for all newborns.

Answer 81

Newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following three characteristics: ● Term gestation? ● Crying or breathing? ● Good muscle tone? If the answer to all three of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing . The initial steps of resuscitation are to provide warmth by placing the baby under a radiant heat source, positioning the head in a “sniffing” position to open the airway, clearing the airway if necessary with a bulb syringe or suction catheter, drying the baby, and stimulating breathing. If the answer to any of the above assessment questions is “no,” the infant should receive an initial assessment and one or more of the following four categories of action in sequence: Initial Assessment: Determine if newborn can remain with the mother or should be moved to a radiant warmer for further evaluation and care. A. Airway Perform initial steps to open the airway (reposition, open mouth, clear secretions if necessary). B. Breathing Newborns with apnea or bradycardia may need positive-pressure ventilation, and newborns with labored breathing or low-oxygen saturation may need continuous positive airway pressure (CPAP) or oxygen therapy. C. Circulation If the newborn has severe and persistent bradycardia despite assisted ventilation, perform chest compressions coordinated with PPV. D. Drug If assisted ventilation and coordinated compressions are unsuccessful and severe bradycardia persists, administer epinephrine and continue with PPV and chest compressions.

Answer 82

Pain associated with labor has been described as one of the most intensely painful experiences possible. Labor pain differs from other conditions in which pain is experienced in several ways. During the first stages of labor pain is caused by uterine muscle hypoxia, accumulation of lactic acid in the muscles, lower uterine and cervical stretching, traction on pelvic organs, and pressure on the bony pelvis. The size and position of the fetus can also demonstrate pain in the pelvis, rectal and adnexae and cause discomfort as well as lumbosacral plexus. During the second stage, pain is caused by pelvic muscle distention and pressure on the perineum, cervix, urethra, and rectum. Back pain during labor is thought to be caused by pressure of the fetal occiput on the maternal spine and pelvis. Factors influencing pain response include both the physical and psychosocial: ● Rate of cervical dilation and strength of contractions. ● Size and position of fetus impacts length of labor. ● Sleep deprivation and exhaustion from long labor increases pain perception. ● Culture of the woman influences her response to labor and pain. Pain behaviors are culturally bound. ● The woman’s labor support system can affect her anxiety level and perception of pain. ● Previous birth experiences may increase or decrease anxiety. ● Childbirth preparation may decrease anxiety and decrease pain. ● The woman’s expectations influence her satisfaction with her birth experience. Pain in childbirth is transmitted from the periphery of the body along nerve pathways to the brain. This pain is attributable to: ● Uterine contractions resulting in uterine pain from a decrease in blood supply to the uterus. ● Increased pressure and stretching of the pelvic structures resulting in the pulling and expansion of ligaments, muscle, and peritoneum. ● Cervical dilation and stretching resulting in the stimulation of the nerve ganglia.

Answer 83

It is well-established that pain is a highly complex phenomenon that involves biological, psychological, and social variables, and that is especially true of women’s experiences of pain in labor. Cultural differences have been identified in women’s experiences of pain in labor. Patients’ culturally-based responses to pain are often divided into two categories: stoic and emotive. Stoic patients are less expressive of their pain and tend to “grin and bear it.” They may tend to withdraw. Emotive patients are more likely to verbalize their expressions of pain. Whether a patient is stoic or emotive may reflect his or her cultural background. If we use such broad generalizations to help understand human behavior, however, we must always keep in mind that while culture is a framework that directs human behavior, not everyone in every culture conforms to a set of expected behaviors or beliefs. Communication with patients can be improved and patient care enhanced when we make efforts to bridge the divide between cultures and the beliefs and practices that make up patients’ value systems (ACOG, 2011b). Through careful listening and probing nurses can uncover what is really happening with each patient’s pain. Sometimes pain measurement tools that rely on numbers or any kind of linear format, such as a row of faces, may not work well across cultures.

Answer 84

This theory states that sensation of pain is transmitted from the periphery of the body along ascending nerve pathways to the brain. Because of the limited number of sensations that can travel along these pathways at any given time, an alternate activity can replace travel of the pain sensation, thus closing the gate control at the spinal cord and reducing pain impulses traveling to the brain. Based on this premise, the application of pressure to certain areas of the body, the cutaneous stimulation such as effleurage (gentle stroking of the abdomen) or the use of heat or cold, can have a direct effect on closing the gate, which then limits the transmission of pain. A similar gating mechanism can be found in the descending nerve fibers from the hypothalamus and cerebral cortex. Strategies such as breathing, focusing, and visual and auditory stimulation may affect whether pain impulses reach the level of conscious awareness.

Answer 85

Non-pharmacological management of labor discomfort includes preparation by the woman for childbirth, cutaneous stimulation, thermal stimulation, mental stimulation, and the presence of a support person(s). It is essential that nurses have a repertoire of strategies to help patients manage discomfort and pain during labor. A willingness to try a variety of strategies, adapt those that are effective, and modify and abandon those that are ineffective is an important aspect of care. Usually, no one strategy works for very long in labor, making flexibility and adaptability key qualities for labor nurses. ● Childbirth preparation methods: Education and explanation of birth process is offered through classes to the woman and her support person before the delivery time. In these classes, the woman and her partner learn about pregnancy, the labor process, the painful aspects of labor, and methods to help relieve the discomforts of pregnancy and childbirth.

Answer 86

● Relaxation and breathing techniques: Varied breathing patterns that promote relaxation and avoidance of pushing before complete cervical dilation. Most childbirth preparation methods teach some form of relaxation and breathing techniques. Most women are taught to take a deep breath at the beginning of the contraction to signal the onset of the contraction and then to breathe slowly during the contraction. As labor pain increases, the woman may need to breathe in a more rapid and shallow manner. On occasion, a woman will experience hyperventilation from this type of breathing. Symptoms are related to respiratory alkalosis and include tingling of the fingers or circumoral numbness, lightheadedness, or dizziness. This undesirable side effect can be eliminated by having the woman breathe into a bag or cupped hands. This causes her to rebreathe carbon dioxide and reverses the respiratory alkalosis. Discuss with the woman and her support team how they plan on managing labor. This will stimulate conversation, facilitate a plan of care to assist them in pain management, and give an opportunity to teach and or support them as needed.

Answer 87

● Effleurage is cutaneous stimulation by lightly stroking the abdomen in rhythm with breathing during contractions. Another form of cutaneous stimulation is back massage and/or counter pressure to the sacral area by another. Counter pressure is exerted to the sacral area with the heel of the hand or fist to relieve the sensation of intense pain in the back caused by internal pressure of the fetal head. This increased internal pressure by the fetal head is often associated with the posterior position of the fetus during labor. As labor advances, women may not want to be touched.

Answer 88

● Thermal stimulation: Application of warmth or cold, such as use of warm showers or ice packs. The use of hydrotherapy via whirlpools, warm baths, or showers is very effective and promotes relaxation and comfort. This may reduce the woman’s anxiety and promote well-being, causing a reduction in catecholamine production that interferes with uterine contractility. Application of cold may release musculoskeletal pain, and the numbing effect of cold may decrease the sensation of pain.

Answer 89

● Mental stimulation: Focal points, imagery, and music help the woman to concentrate on something outside her body. This helps her to focus away from the pain. With imagery, the woman is encouraged to picture a relaxing scene.

Answer 90

● Support person(s): Significant other(s) and/or a doula provide emotional support and physical comfort and aids in a beneficial form of care. Research has shown that support early in labor significantly relieves pain, improves outcomes, decreases interventions and complication rates, enhancing overall maternal satisfaction (Simkin & O’Hara, 2002). A doula can also be used as a support for women during pregnancy through postpartum. Doulas are unique in that they are trained to provide support, promote comfort, and instill confidence to the laboring woman. Doulas are trained through many organizations and paid by the family that hires them. Doulas do not perform clinical tasks and do not have direct communication responsibility to care providers (Burke, 2014). Some studies have shown that women who used a doula had shorter labors, less use of analgesia, fewer instrument deliveries, and fewer C-sections

Answer 91

Many therapies have been used to promote relaxation and decrease the perception of pain while providing a complement to decrease the use of pharmacological interventions. ● Aromatherapy: Essential oils can be inhaled through vaporizers or used in a carrier oil or lotion with massage to promote relaxation and decrease the perception of pain. A few drops placed in a bath can be an adjunct to hydrotherapy. Lavender and jasmine oils promote relaxation and decrease pain perception, while peppermint may decrease feelings of nausea. ● Massage: Multiple studies have shown massage to decrease pain and promote relaxation, which in turn promotes labor progress. A quiet, soothing voice encouraging the woman to imagine a safe place can assist in relaxation. This used in conjunction with aromatherapy has proven to enhance relaxation in laboring women, allowing women to have better control of labor. ● Birthing ball: This ball (65-cm) originated in physical therapy programs but has been used successfully in the labor suite. It facilitates an upright position, opens the pelvis, and allows the woman to roll or bounce as she deems necessary to manage her contractions and pain. ● Hydrotherapy: Water has been used in many areas of medicine for many years to promote relaxation and pain control. The use of a shower or large tub is ideal for releasing endorphins, decreasing muscle tension, and promoting circulation. The use of hydrotherapy with ruptured membranes (ROM) has shown no increase of infections. The many benefits of hydrotherapy include less medication needs, less anesthesia, faster labors, facilitation of fetal positions (which decreases the number of instrumental deliveries), fewer episiotomies, decrease in blood pressure and edema, promotion of diuresis, and increased satisfaction in the birthing experience. Data indicates hydrotherapy is a safe nonpharmacologic measure (AWHONN, 2008). ● Self-hypnosis: Use of self-hypnosis during labor and birth has been investigated and studies suggest it can reduce labor pain and requests for parenteral analgesia and regional analgesia/anesthesia during labor (AWHONN, 2008). The use of self-hypnosis as a method to decrease pain during labor has not been widespread in North America. ● Music therapy: Music calms the spirit and decreases stress and distress by diverting attention from the pain receptors and promoting relaxation. ● Acupuncture: This traditional Chinese therapy improves energy flow, reduces pain and anxiety, and helps labor progress (Simpkin, Hanson, & Ancheta, 2017). ● Sterile water injections: SQ injection of .5 ml of sterile water gives about 60-90 minutes of lower back pain relief

Answer 92

Most classes teach a variety of strategies to manage labor pain. Specific methods include: ● Dick-Read method: Advocates birth without fear by education and environmental control and relaxation. ● Lamaze: Promotes psychoprophylaxis with conditioning and breathing. ● Bradley: This is husband-coached childbirth and support focused on working with and managing the pain rather than being distracted from it.

Answer 93

A registered nurse or other members of the care team with licenses must supervise non-licensed individuals performing labor support interventions. Individuals must have evidence-based knowledge concerning how to perform and customize non-pharmacologic labor support interventions. Non-pharmacologic labor support is discussed earlier in the chapter and a summary of nursing interventions include the following: * Stay in the room with the woman. * Encourage the woman to labor in positions of her choice, e.g., walk or use a balance ball. * Interventions and strategies can include: * Guided imagery and therapeutic breathing * Touch therapy, such as a back rub, leg massage, or counter pressure * Hydrotherapy in a tub or shower * Application of warm or cool compresses to various parts of the woman’s body * Aromatherapy * Provide emotional support: Verbally encourage, reassure, and praise the woman and provide easy to understand information about how labor is progressing and how she and her baby are doing; * Support the woman’s nutritional needs * Advocate for the woman by helping her articulate her wishes to others.

Answer 94

The perinatal nurse is an integral member of the health care team who works collaboratively with the obstetric and anesthesia health care providers to address women’s needs for pain management during labor and birth. As the need for a wide variety of pain management options has emerged, researchers have focused on enhancing the efficacy and safety of various forms of obstetric analgesia and anesthesia, including neuraxial, or regional, analgesia for childbirth. Pharmacological management of discomfort and pain requires the nurse to assess the woman’s preferences for pain management throughout labor. The decision to use pain medication in labor should be made by the woman in collaboration with her physician or midwife. The unique circumstances of every labor influence the experience and perception of pain ● Assessment of pain is an essential part of nursing care. ● Assessment of labor pain should include intensity, location, pattern, and degree of distress for the woman, as well as using pain scale with numerical self-report using a scale of 1 to 10. ● The use of medication in the relief of pain during labor falls into two major categories: Analgesia (Table 8–3) and anesthesia (Table 8–4). ● Basic principles when using analgesia include: ● Labor should be established. ● Medication should provide relief to the woman with minimal risk to the baby. ● Neonatal depression may occur if medication is given within an hour before delivery. ● Women with a history of drug abuse may have a lessened effect from pain medication and require higher doses. ● Basic principles for anesthesia include: ● Local anesthesia is used at the time of delivery for episiotomy and repair. ● Regional anesthesia is used during labor and at delivery. ● Regional anesthesia includes the pudendal block, epidural block, and spinal block. ● Regional or general anesthesia is used for cesarean deliveries.

Answer 95

The use of opioids in labor is common. Advantages include availability, ease of administration, and cost. Depending on the dose, route of administration, and stage of labor parenteral analgesia does not illuminate pain but causes a blunting effect, leading to a decrease in sensation of pain and inducing somnolence (Burke, 2014). Opioids cross the placenta and can cause neonatal respiratory depression

Answer 96

In the context of obstetric analgesia, “nitrous oxide” usually refers to a half-and-half combination of oxygen and nitrous oxide gas, called by the trade name “Nitronox.” It is self-administered by the laboring woman using a mouth tube or face mask when she determines that she needs it, about a minute before she anticipates the onset of a strong contraction until the pain eases. Its use can be started and stopped at any point during labor according to the woman’s needs and preferences. It takes effect in about 50 seconds after the first breath and the effect is transient—essentially gone when no longer needed. It is simple to administer and does not interfere with the release and function of endogenous oxytocin, and has no adverse effects on the normal physiology and progress of labor. This analgesia may be of help for women who want to have an unmedicated birth but may need help at some point during labor and want to use a method that is under their control

Answer 97

Epidural anesthesia involves the placement of a very small catheter and injection of local anesthesia and or analgesia between the fourth and fifth vertebrae into the epidural space. A combined spinal epidural analgesia (CSE) involves the injection of local anesthetic and/or analgesic into the subarachnoid space. Some patients may be able to ambulate with this type of anesthesia, so it’s sometimes called a “walking epidural.” Because of the widespread use of epidural anesthesia in labor, AWHONN has generated evidence-based practice guidelines for care of pregnant women receiving regional anesthesia/analgesia Some research shows that epidural analgesia is associated with a lower rate of spontaneous vaginal delivery, a higher rate of instrumental (e.g., vacuum suction and/or forceps) vaginal delivery, longer labors, and increased incidence of intrapartum fevers and/or suspected sepsis. Elevations in maternal temperature associated with regional anesthesia have been reported and may not be clinically significant. They may be associated with decreased maternal hyperventilation, reduced perspiration, and altered thermoregulatory transmission. ● A wide variety of medications and dosing regimens are used for regional analgesia/anesthesia. Nurses are responsible for knowing general information about classification of these medications, their actions, potential side effects, and complications. Epidural labor analgesia involves the placement of a catheter and injection of a local anesthetic or analgesic agent or both into the epidural space, typically in the lumbar region. Partial loss of sensation may occur. * Nurses monitor but do not manage the care of women receiving epidural anesthesia. * Catheter dosing of intermittent and continuous infusion of regional analgesia/anesthesia is outside the scope of registered nursing. * Only qualified, licensed anesthesia providers should perform insertion, injection, and/or manage rate changes of a continuous infusion (AWHONN, 2011b). * Responsibilities of nurses caring for women receiving regional anesthesia/analgesia are assessment, monitoring, and interventions to minimize complications. * After the stabilization of the patient after regional anesthesia, the nurse monitors the woman’s vital signs, mobility, level of consciousness, and perception of pain, as well as fetal status.

Answer 98

● Assess woman’s level of pain. ● Determine the woman’s and her family’s knowledge and concerns about epidural anesthesia. ● Provide information about options for anesthesia/analgesia. ● Notify obstetrical and anesthesia care providers when the woman requests epidural anesthesia. ● Assess and document baseline blood pressure, pulse, respiratory rate, and temperature. ● Assess FHR to confirm a normal FHR pattern; if indeterminate or abnormal, report to the physician or midwife. ● Encourage the patient to void before initiation of epidural anesthesia. ● If ordered, administer an IV bolus as ordered to decrease incidence of hypotension. ● Obtain platelet count, blood type, and screen. ● Conduct a pre-procedure verification process per facility policy. ● Conduct time-out. The time-out involves the immediate members of the procedure team: the anesthesia provider and the nurse. During the time-out, the team members agree and verify the correct patient identity, the correct site and the procedure to be done (Joint Commission on Accreditation of Healthcare Organizations, 2017).

Answer 99

● Assist the anesthesia provider, anesthesiologist, or nurse anesthetist (CRNA) with placement of the epidural, including placement of patient in the lateral position with head flexed toward chest, or sitting position with head flexed on chest, elbows on knees and feet supported on stool

Answer 100

● Monitor vital signs according to agency protocols, generally every 5 to 15 minutes. Assess for hypotension and respiratory distress. ● Up to 40% of women may experience hypotension. Difficulty breathing may indicate the catheter is in the subarachnoid space. ● Hypotension is defined as systolic blood pressure less than 100 mm Hg or a 20% decrease in blood pressure from preanesthesia levels. Notify the anesthesia provider if the patient becomes hypotensive. ● Assess FHR every 5 to 15 minutes. ● Facilitate lateral or upright positioning with uterine displacement. ● Helps to avoid supine hypotension ● Assess for effectiveness of the epidural and the woman’s pain levels and description of pain. ● Notify the anesthesia provider of inadequate pain relief. ● Assess for sedation if opioid medication is administered with local anesthesia. ● Drowsiness can occur in up to 50% of women who receive combination local/opioid analgesia. ● Assess the level of motor blockade according to agency criteria. ● If the patient receives an epidural that allows ambulation: Before ambulation, the nurse assesses somatosensory status, motor strength, and ability to ambulate. ● Monitor for pruritis. ● Up to 90% of women who receive opioids in epidurals have itching. Medicate as indicated. ● Monitor for nausea and vomiting. ● Up to 50% of women experience this and may be treated with antiemetics. ● Assess for post-procedural headache. ● Occurs in up to 3% of women related to leakage of spinal fluid with inadvertent puncture. If this occurs, it should be reported to the anesthesia provider. ● Assess the woman for urinary retention. ● This occurs in some women who receive epidural anesthesia because of decreased motor function. Catheterization is typically necessary. ● Assess the partner’s or support person’s response to epidural pain relief and answer questions. ● Monitor uterine contractions as uterine activity may slow for up to 60 minutes after epidural placement. This may be a side effect of the neuroaxial block and usually no treatment is needed. Some providers will initiate oxytocin augmentation to stimulate contractions. ● Monitor for signs and symptoms of intravascular injection including: This normally occurs during placement and is monitored by a test dose being given by the anesthesiologist. ● Maternal tachycardia or bradycardia ● Hypertension ● Dizziness ● Tinnitus (ringing in the ears) ● Metallic taste in the mouth ● Loss of consciousness If intravascular injection occurs, the anesthesia care provider should be immediately notified and care includes administering oxygen, fluids, and medication as ordered. Initiating CPR may be necessary. ● A higher level of anesthesia is necessary for a cesarean birth than for labor

Answer 101

Based on the research data a theory, “cruising through labor,” was developed. The epidural labor process is different from non-epidural labor and is comprised of six phases: ● Holding out ● Surrendering ● Waiting ● Getting ● Cruising ● Pushing Expectant fathers explained that before the epidural they felt like they were “losing” their partner as the increasing pain caused the woman to focus inward and away from interaction with those in the labor room. The expectant fathers explained that they felt a loss of connection with their partner and a loss of control. They felt that the pain of labor overtook their partner and was all-encompassing. The men further explained that they felt helpless, frustrated, and a sense of losing her to the pain of labor. The men explained that the labor nurse played a significant role in supporting them during this time. The major supportive behaviors by the nurse were: ● Remaining in the labor room ● Explaining what was happening to their partner ● Including the men in the care of their partner Expectant fathers reported that once the epidural was administered and the woman experienced relief from labor pain, they saw a dramatic change in their partner’s behavior. They often stated, “She’s back,” that she was comfortable and able to interact with those around her. One man stated, “She wasn’t in pain. Her color was back. Her pain was gone. She wasn’t throwing up. She was back. She was comfortable.”

Answer 102

See on page 263

Answer 103

For Labor and Birth First Stage of Labor Goal: Safe delivery for mother and baby Outcome: Safe delivery for mother and baby Nursing Actions 1. Perform admission procedures and orient patient to setting. 2. Review prenatal records. 3. Assess FHR and uterine activity. 4. Assess maternal vital signs and pain. 5. Assist with ambulation and maternal position changes. 6. Provide comfort measures. 7. Discuss pain management options. 8. Administer pain meds PRN. 9. Monitor I&O and provide oral and/or IV hydration as indicated. 10. Provide ongoing assessment of labor progress. 11. Request an immediate bedside evaluation by a physician or CNM. Second Stage of Labor Goal: Safe delivery for mother and baby Outcome: Safe delivery for mother and baby Nursing Actions 1. Perform more frequent maternal and fetal assessment. 2. Review prenatal records. 3. Assess FHR and uterine activity. 4. Assess maternal vital signs and pain. 5. Encourage open glottis pushing efforts. 6. Provide comfort measures for pushing efforts. 7. Provide ongoing assessment and encouragement of labor progress. 8. Communicate with interdisciplinary team. 9. Prepare for delivery. Third Stage of Labor Goal: Safe delivery of placenta and transition for baby Outcome: Safe delivery of placenta and transition for baby Nursing Actions 1. Facilitate family bonding. 2. Assess maternal vital signs and pain. 3. Assess maternal stability. 4. Prepare for delivery of placenta and need for uterotonics. Fourth Stage of Labor Goal: Safe recovery of mom and baby Outcome: Safe recovery of mom and baby Nursing Actions 1. Facilitate family bonding. 2. Assess maternal vital signs and pain. 3. Assess maternal stability, fundus, lochia, bladder, perineum. 4. Provide comfort measures and pain meds. 5. Initiate breastfeeding. 6. Provide food and fluids for patient when stable.