labor and birth (unit 1) Flashcards
cardiovascular changes during labor
- during ctx 400 mL blood emptied from uterus into maternal system
- mom CO, BP, HR increase
- blood flow to placenta decrease
cardiovascular NSG Imp during labor
- check VS b/t ctx
- discourage Valsava maneuver
- keep off back
- monitor BP hourly
respiratory changes during labor
- > O2 consumption
- depth/rate respirations inc. w/ pain
- hyperventilate (risk for alkalosis)
respiratory NSG imp during labor
- monitor for tingling, numbness, dizziness (resp. alkalosis)
- have pt breathe into cupped hands
GI changes during labor
- GI motility dec.
- thirst/dry mouth
- N/V; belching @ full dilation
GI NSG imp during labor
- admin anti-emetic (Phenergan)
- keep NPO (exc. ice chips)
- monitor for Mendelson’s syndrome
Mendelson’s Syndrome
- aspiration of food or acidic gastric contents leads to pneumonia
- prevented by keeping women in labor NPO in case general anesthesia required
renal/GU changes during labor
•spontaneous voiding difficult
-tissue edema after birth
-regional anesthesia (epidural)
•proteinuria 1+ normal b/c breakdown of muscle tissue
renal NSG imp during labor
- maybe cath
- encourage void q2h
- swollen bladder makes it difficult for baby to progress
blood changes during labor
- H&H of >11g/dL and 33% will prevent complications
- WBC inc
- clotting factor inc
- SVD: lose 500 cc blood
- C/S: lose 1000 cc blood
NSG Imp blood changes during labor
•know admission H&H to compare w/ PP
•monitor blood loss
***1st sign of hypovolemia is tachycardia
fetal circulation during labor
•during ctx, blood to placenta from mom dec.
•placental exchange occurs b/t ctx to supply enough for fetus
*why resting phase is important
NSG Imp fetal circulation during labor
•ensure ctx not too close or last too long
fetal pulmonary system
•lungs filled w/ fluid as fetus •labor prepares fetus for respirations -PO2 dec -CO2 inc -pH changes -temp changes
vaginal squeeze
•during birth, fetal thorax is squeezed and fld is expelled into upper airway
-surfactant prevents alveoli from sticking
•c/s baby will have more difficulty breathing
doulas
- female labor attendant
- one on one physical/emotional care
- DONT provide medical care
- don’t leave at shift change
- act as advocate
what starts birth
•no single cause
- distention of uterus
- cervix ripen
- pit release oxytocin
- fetal/maternal hormone inc
- aging placenta
- changes take place days-weeks before labor begins
pitocin
- drug derivative of oxytocin
- ctxs the uterus
- given to mom after delivery
lightening
- preceding labor sign
* baby descends into pelvis
bloody show
- preceding labor sign
- capillaries in cx break, so blood mixed w/ mucous
- pink (bright red is concerning)
mucous plug
- preceding labor sign
- up to 2 weeks prior
- “wine cork” that comes out of os when cervix ripens
other signs preceding labor
- braxton hicks ctx
- increased energy
- nesting instinct
- wt loss
- GI s/sx
7 cardinal movements
•position changes fetus undergoes to move thru birth canal
- engagement
- descent
- flexion
- internal rotation
- extension
- restitution
- expulsion
engagement
- widest part of fetal head passes pelvic inlet into station 0 or lower (in line of maternal pelvis)
- primips: 2-3 wks prior to birth (dropped)
- multips: occurs during labor
descent
- head progresses thru pelvis
* accelerates after 5-7 cm
flexion
- head becomes maximally flexed b/c meeting resistance w/ cervix/pelvic floor
- chin to chest makes smaller diameter that has to pass thru cervix
internal rotation
•fetal occiput rotates to lateral anterior position as it progresses to lower pelvis in corkscrew motion
extension
- fetus extends neck as passes thru symphysis
* head deflected anteriorly and born by extension of chin away from chest
restitution
•head turns 45 degrees back to position it occupied as it entered pelvic inlet to realign w/ shoulders
expulsion
- first anterior, then posterior shoulders are born (down then up)
- followed by the rest of the body
5 factors effecting labor (Ps)
- passenger
- passageway
- power
- position
- psyche
passenger
- fetus and placenta
* fetal ability to navigate birth canal based on head size, presentation, lie, altitude, and position
fetal head size
- not fused, so molded as passes thru canal
* fontanels allow bones to move and change shape
fetal presentation
- part of fetus that enters pelvis first
- cephalic 96%
- breech 3%
- shoulder 1%
vertex or occiput presentation
- back of head presents first
* preferred
military presentation
- neutral position
* top of head presents first
brow presentation
•head partially extended
face presentation
•head fully extended
breech presentation
- buttocks enters pelvis first
- usually r/t problem
- often need C/S
shoulder presentation
- fetus presents in transverse line
* requires C/S
fetal lie
•relationship of fetal spine to mom’s
longitudinal lie
- head/butt in pelvis
* 99% of the time
transverse lie
•long axis of fetus R angle to mom spine
oblique lie
•fetus is at some angle
fetal attitude
- relationship of fetal parts to one another
* normal is w/ head flexed toward chest and arms and legs flexed over thorax; back convex C
fetal position
•relationship of fetal spine to 4 quadrants of maternal pelvis
fetal postion abbreviation
- fetal spine on R or L of maternal pelvis
- Occiput or Sacrum presenting
- Anterior, Posterior, Transverse (side)
passage
•birth canal, which is composed of bony pelvis, cervix, pelvic floor, vagina and introits (vag opening)
gynecoid pelvis
- classic female type
- perfect circle
- 50% of women
anthropoid pelvis
- resembles ape
- vertical egg
- 25% white; 50% nonwhite
android pelvis
- resembles male pelvis
- heart shaped
- 23% of women
platypoid pelvis
- horizontal squashed oval
* 3% of women
passage problem r/t soft tissue
- often due to full bladder
- less space for baby
- intensifies maternal discomfort
- reason to void q2h or cath
primary power of labor
- involuntary ctx
* causes effacement (thinning), dilation, descent
secondary power of labor
- voluntary pushing once head reaches pelvic floor (+1 or lower)
- triggers Ferguson reflex that tells body to push (diminished if had epidural)
- causes descent
1st stage of labor
•12.5 hr •begins w/ onset •ends w/ complete dilation •includes latent, active, transition phases *dilation stage
latent phase
- cervix 0-3 cm
- irregular mild/moderate ctx q 5-30 min
- ctx duration 30-45 sec
- lots of effacement and fetal position changes
active phase
•cervix 4-7 cm •regular/stronger ctx q 3-5 min •ctx duration 40-70 sec •fetus starts to descend •anxious, serious, demanding *time to go to hospital
transition phase
•cervix 8-10 cm •very strong ctx q 2-3 min •ctx 45-90 sec duration •bloody show, further descent •hypervent, irritable, anger, N/V, etc ***DONT leave her alone
2nd stage of labor (expulsion of babe)
•fully dilation to birth of baby •progress into intense ctx q 1-2 min •60-70 sec ctx duration (rest) •pushing results in birth of fetus *pushing stage
spontaneous vs. controlled pushing during 2nd stage
- spontaneous pushing- pt controlled
* directed pushing- nurse controlled
3rd stage of labor (expulsion of placenta)
•begins w/ delivery of neonate •ends w/ delivery of placenta (shortest stage) •uterus rises when placenta enters vagina •cord lengthens •gush of blood •continuous ctx •post-partum ctx afterpains *placental stage
4th stage of labor (recovery)
•begins w/ delivery of placenta •ends w/ maternal VS stabilization (2-4 hrs) •happy, laughing, excited •best time for bonding/breast feeding *physical recovery
uterine body during ctx
- upper ⅔ actively push fetus down
- lower ⅓ allows passive downward mvt
- causes cervix to efface/dilate
cervix effacement
- thins/shortens during 1st stage of labor
- written as percentage (dilation, effacement, station)
- primip: efface then dilate
- multips: dilate then efface
- Ex: 3 cm dilated; 1.5 cm effaced (50%); -3
fetal station
- measurement of fetal descent
- level of ischial spines = 0 (engaged)
- -5 to 0 is how many cm above (balotable)
- 0 to +5 is how many cm below
upright positions during labor
- aid gravity and shorten labor
- better CO, so more blood flow
- walking, sitting, kneeling, squating
only position woman should NOT assume during labor
- supine
* r/o Vena cava syndrome- compression of aorta/vena cava by uterus (hypotension/fetal acidosis)
when should woman go to hospital
- primp: regular, painful ctx q 5 min x 1-2 hours
- multip: regular, painful ctx q 5-10 min x 1 hr
- bright red bleeding
- ROM
- decreased fetal movement (< 4-6 x hr)
true labor
•painful, regular ctx which worsen w/ walking
•low back wrap to front pain
*progressive ctx change
Braxton Hick’s (false labor)
•ctx irregular and not painful
•walking stops ctx
•pain mainly in low back
*no progressive ctx change
determining rupture of membrane (ROM)
•sterile speculum exam w/ fern test
•pooling of amniotic fld
•nitrazine tape or pH paper
-easy to contaminate
fern test
- ONLY definitive way to know if fld is amniotic
- dries w/ specific pattern
- mucus won’t dry with the pattern
meconium
- baby’s first poop
- turns amniotic fld green/brown and thick
- issue if really green/brown b/c baby breathing in
visceral pain during labor
- slow deep pain
- cervical dilation in 1st stage (“everywhere”)
- ctx (“back”)
somatic pain during labor
•localized, intense, sharp •2nd stage- descent of fetal head •perineal tearing •"burning" *this part can't be controlled w/ epidural
benefit of using relaxation techniques during labor
- inc. uterine blood flow -> inc. fetal O2
- inc. ctx efficiency
- dec. pain perception
- dec. tension -> fetal descent
cutaneous stimulation during labor
- inc. circulation
- decreases muscle tension
- massage (effleurage), thermal, pressure, hydrotherapy, etc
hydrotherapy
- dec. catecholamines
- trigger oxytocin release
- release endorphins
- dec. BP
slow paced breathing
- used during 1st stage of labor
* slow, deep, in nose out mouth
modified paced breathing
•shallow, faster chest breathing
patterned-pced breathing
- pant-blow
* hee hee hee who
problems w/ breathing during labor
•dry mouth •hyperventilation -resp. alkalosis -lose CO2 -dizzy, lightheaded, tingling *RN: breath into bag/hands
pharmacologics that enhance labor
•allow relaxation of tense muscles
pharmacologics that slow labor
•prevent effective pushing
direct effects of pharmacologics on fetus
•drugs pass thru placenta to fetus
•dec. FHR w/ demerol or MgSO4
***best to give during ctx b/c no transfer to fetus then
indirect effects of pharmacologics on fetus
- affect mom, causing side effect in fetus
* Ex: epidural causes vasolilation and if mom BP dec. too much, fetus hypoia/acidosis
meperidine (Demerol)
•major method of pain relief if epidural not available
•good pain control w/o loss of consciousness
•rapid onset long duration
•# SE is resp. depression in baby (have NArcan ready)
***typically admin w/ Phenergan
Fentanyl (Sublimaze)
•pain control during labor •rapid onset, short duration (IV) •less N/V and sedation than Demerol *preferred b/c less SE and short t1/2 *diff. side effects when in epidural
butorphanol
•pain control during labor •Stadol •Nubain- DONT give if opioid previously or abuse *short duration drugs *no risk of resp. depression
Phenergan (Promethazine)
•co-drug that potentiate opioids and tranquilize •decreases anxiety •anti-emetic •IV or IM *give 50 mg Demerol w/ 12.5 mg Phenergn
Vistaril (Hydroxyzine)
- antihistamine w/ antiemetic and sedative effects
- IM Z track
- prevents nausea and promotes rest
Narcan
- reverses opioid related resp. depression in mom AND baby
* doesn’t reverse resp. depression due to other causes
NSG imp if giving drugs
- admin so babe not born at peak
- give at beginning of ctx so drug goes to mom instead of directly to babe
- monitor resp status of babe
what must be done prior to medicating?
- check dilation
- be ready to admin during during ctx so drug goes to mom and not through placenta to baby
- monitor mom and baby continuously
what if babe born w/in 60 min drug admin?
•if opioid give baby narcan
regional pain management
- provides temporary loss of sensation by injecting anesthetic agent into nervous tissue
- epidural or spinal
- no loc
- fetal effects based on maternal rxn, not drug effects b/c indirect
AE of eipdural
***hypotension (r/t vasodilation) •bladder distention (r/t dec. sense) •prolonged 2nd stage (r/t pelvic relax interfere w/ rotation) •catheter migration •increase C/S rate •fever (r/t long labor) •pruritis (itching)
epidural admin NSG imp
- give pre-epidural IV bolus of 500-1000cc LR
- monitor BP, P, FHR, bladder
- position changes
- encourage pushing @ +1/+2 station if uncomfortable
spinal anesthesia (subarachnoid block)
•quicker than epidural for C/S
•hypotension/HA likely
•quick onset, short duration
*never used for vaginal birth
local anesthesia
- injected into perineum (esp. during episiotomy)
- no ctx pain relief
- rapid onset
general anesthesia (GETA)
•only used in emergency
•high r/o acid aspiration syndrome, resp depression, uterine relaxation
*have narcan and Pitocin ready
when to call MD during labor
•first sign of crowning
after birth of placenta
- admin pitocin
- monitor maternal VS q 15 min x 1 hr
- obtain cord blood if needed (mom Rh-)
- send placenta to lab
- cleanse perineal area
best time to breast feed
- w/in 1st hr of birth
* helps ctx fundus
soaking more than one pad/hr postpartum worried about…
•hemorrhage
Your patient is a G7 T0 P0 (preterm) Ab6 (abortion) L0. She is 36.5 weeks and is complaining of backache and says she had diarrhea this morning
- signs of early labor
* need to find out info about post pregs, allergies, etc
abortion types
- spontaneous- miscarry
* elective
Your patient is a 13 year old G1 at 39 weeks. Vag exam: 3-4/100/-3, “gross” ROM verified by fern. Ctx: q 5-7 min; moderate to palpation
- water broken (admit)
- concerned about support and position of fetus (chord could fall out first)
- b/t latent and active phase
Your patient is a G1 in the late latent phase of labor. What would dilation be?
- 1-3 cm
* encourage walking
A client reports that her contractions started about 2 hours ago, did not go away when she had two glasses of water and rested, and became stronger since she started walking. She tells the nurse that the contractions occur every 10 min and last about half a minute. She hasn’t had any fluid leak from her vagina; however, she did not think she saw some blood when she wiped after voiding. Based on these reports, the nurse should recognize that the client is experiencing?
true contractions
A nurse applies an external fetal monitor and tocotransducer to monitor the FHR and contractions of a client who is in labor. The FHR is around 140/min. Contractions are every 8 min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of labor is the client experiencing?
stage 1 latent phase
A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. The nurse’s first nursing action after establishing that the fluid is amniotic fluid should be to.
- monitor FHR for distress b/c r/o umbilical cord prolapse
* then assess amniotic dld color, dry pt, and monitor uterine ctx
A nurse is caring for a client who is primipara and in active labor. The client received meperidine (Demerol) 50mg IV for pain 30 min prior to a precipitous delivery. Which of the following medications should the nurse be prepared to administer.
Narcan to the neonate for respiratory depression
A nurse is caring for a client who is in labor. Which of the following should the nurse assess for following placement of an epidural?
maternal hypotension
*should also monitor for fetal bradycardia
gravida
•pregnancy
para
- delivery
- primipara- first delivery
- muldipara- not first delivery
fever indicates
- infection in amniotic fluid after ROM
* fetus becomes tachycardic
when to r/o cord prolapse
- variable deceleration of FHR
* ROM w/ fetus in negative position
