Labor & Delivery Flashcards
Labor definition
Series of events by which uterine contractions and abdominal pressure expel the baby form the mother’s body
CPD
cephalopelvic disproportion
Amniotic fluid embolism
Placental circulation carries amniotic fluid into venous flow
Version
Turning infant from malposition to cephalic
Preliminary signs of labor
- Lightening
- Increase in level of activity
- Braxton Hicks contractions
- Ripening of the cervix
Signs of true labor
- Uterine contractions
- ROM
False contractions
- begin and remain irregular
- remain confined in abdomen and groin
- disappear with ambulation and sleep
- do not increase in duration, frequency, or intensity
- do not achieve cervical dilation
True contractions
- begin irregular but become regular
- first felt in lower back then the abdomen in a “wave”
- continued no matter level of activity
- increase in duration, frequency, and intensity
4 Components (“4P”s) of Labor
- Passenger
- Passage
- Powers
- Psyche
Passenger (4P’s)
Passengers - fetus, placenta, cord, fluid, and membranes
refer to slide 13
Passage (4P’s)
Pelvis, Vagina, Perineum
Powers (4P’s)
Involuntary uterine contractions, bearing down efforts
Psyche (4P’s)
Fear, pain, anxiety
Attitude
- Pose assumed within the uterus – flexion most common
- Relationship of fetal body parts to each other
Fetal lie
- Relationship of long axis of fetus to long axis of mother
- Longitudinal most common
Fetal positions
Relationship of fetal head/bottom/shoulder to the Mom’s pelvis
Vertex Presentation (Occiput)
LOA, LOP, LOT, ROA, ROP, ROT
Breech Presentation (Sacrum)
LSA, LSP, LST, RSA, RSP, RST
Face Presentation (Mentum)
LMA, LMP, LMT, RMA, RMP, RMT
Shoulder Presentation (Acromion process)
LAA, LAP, RAA, RAP
Leopold’s Maneuver
- Determines the position of the baby so can see the points of maximum intensity of the FHT
- Performed by nurses/providers
Malpresentations
include: face, brow, breech, (can try to change this with version) transverse lie, shoulder
Malposition
most common is posterior (OP) try hands/knees position & counter pressure (back)
Multiples
small babies, uterine dystocia, abn presentations of twins (?surgery), anomalies
Abnormalities of placenta
- Placenta succenturiata
- Placenta circumvallata
- Battledore placenta
- Velamentous insertion of the cord
- Vasa previa
- Placenta accreta
Abnormalities of the cord
- Two-vessel cord
- Unusual cord length
Vena caval syndrome
- If Mom on back, baby puts pressure on vena cava = poor perfusion to uterus – Possible fetal distress
- TX: side lying
Previa
Complete, partial, marginal
Pt at risk for previa
pts with hx of:
- uterine scarring
- multiple gestation with lg placenta
- endometritis
- previous low implantation,
- older multips
Previa s/s
- intermittent, painless bleeding - usually starts about 28 weeks
- can become hypovolemic
Previa tx
- NO vag exams
- T&C for 2 units (on call)
- Double set up for delivery
- Marginal - can leak fluids thereby put pressure on bleeding point.
- Bed rest
- IV
- Frequent FHT
Abruption
- Marginal, central, complete
- Can occur at any time in the pregnancy
Abruption s/s
- MAY have vag bleeding
- Fetus hyperactive at first then ceases to move
- Uterine tenderness
- Pain
- Change in contr, (tone>hypertonic Fierce contractions)
Abruption tx
- Determine amt of separation and age of fetus
- May treat conservatively with BR, sedatives, and observation
- If severe will need to support blood volume and do c-section
Acreta
Placenta has invaded the uterine muscle
Acreta tx
May require hysterectomy
Cord Prolapse
Occurs with ROM when head NOT engaged or firmly fitted against cx, with CPD, malpresentations, polyhydramnious
Cord prolapse s/s
- Visual or tactile dx
- Deep long variable decel
Cord prolapse tx
Position change
- AROM with slow release of fluid (esp if head is high, BR if ROM & high head)
- If prolapses KNEE CHEST, FILL BLADDER etc to keep head off cord!!
Cord compression
- Occurs when there is not enough fluid to “float” the baby
- Cord around the neck
Cord compression s/s
Deep long variable decel
Cord compression tx
- amniofusion
- position changes
Polyhydramnios
- > 2000 cc fluid
- seen by 3rd trimester
- associated with fetal GI anomalies that inhibit swallowing, CNS defects, sometimes multilpe gestation, and severe diabetes
Complications of Polyhydramnios
- prolapsed cord
- pressure symptoms
Polyhydramnios tx
- Amniocenteses
- Slow/careful ROM in labor
- Pt education
- Indocin to reduce fetal voids
Oligohydramnios
- < 500 cc fluid at term
- associated with renal/GI anomalies, Maternal hypertension, vasoconstriction, IUGR, PROM
- Can be life-threatening as fetus cannot move lungs, cord compression, amniotic leak
Oligohydramnios tx
- Amniofusion
- C-section
Amniofusion risks
- Overdistention of uterus
- Increased uterine tone
Nursing role in amniofusion
- Careful monitoring of infusion,
- Monitoring of intensity and frequency of contractions
- Maternal and fetal vital signs
Immediate interventions of ROM
- Check FHT immediately, observe for cord
- Note color, odor, amount, particulate material
- Chart findings along with the time
Pelvic dystocia
- Pelvis too small or abnormally shaped
- Secondary to maternal anomaly, trauma, malnutrition, low spine disorder, immature
- Leads to malpresentation, cord prolapse
Uterine dystocia (Hypotonic Contraction)
Infrequent and/or mild in intensity, usually in active phase
What is uterine dystocia (hypotonic) r/t?
- Analgesia
- CPD
- Malposition
- Overdistention
Uterine dystocia tx with hypotonic contractions
- Rest uterus
- Augmentation
- Evaluate glucose depletion
Uterine dystocia (Hypertonic Contraction)
Increased frequency, increased resting tone, may see decrease in intensity due to lack of resting tone
Uterine dystocia (hypertonic) r/t?
malfunction of Uterine “pacemakers”
Uterine dystocia (hypertonic) complications
May cause fetal hypoxia, uterine rupture
Uterine dystocia (hypertonic) tx
Medicate, support, comfort measures, evaluate fluid status & stress
PC’s of “powers”
- Precipitate labor
- Uterine rupture*
- Contraction rings
- Inversion of the uterus**
- Amniotic fluid embolism**
Uterine rupture
Emergency situation!!!
- Hypotonic to no contractions
- Burning tearing pain
- Hypovolemic shock
- Palpable fetal parts
- Fetal distress
Bandl’s Ring
- Causes uncoordinated contractions
- Can be identified by sonogram
- Emergency - Can cause uterine rupture, fetal death and hemorrhage if occurs in 3rd stage
Interventions for Bandl’s Ring
- IV Morphine
- Inhalation of Amyl Nitrate
- Tocolytic
- C- section and manual removal of placenta under anesthesia
Psyche
- Increase catacholamines -> dereased blood flow to uterus -> weak contractions -> fetal distress -> anxiety
- Can be seen as lack of control
Psyche tx
Consider preparation
- Culture
- Support
- Self confidence
- Reassure and support
Psychological Responses to Labor (Psyche)
- Fatigue
- Fear
- Cultural influences
Fetal labor danger signs
- Heart rate
- Meconium staining
- Hyperactivity
- Fetal acidosis
Maternal labor danger signs
- Blood pressure
- Abnormal pulse
- Inadequate or prolonged contractions
- Pathologic retraction ring (contraction ring) PC: ruptured uterus
- Abnormal lower abdominal contour
- Apprehension
How is cervical ripening done?
- Prostaglandins (suppository, pill form)
- Luminaria
- AROM
Induction with oxytocin
- Monitored labor!!!!!!!
- Meds on pumps or controller
S/S of preclampsia
- headache
- epigastric pain
- blurred vision
Reasons for induction
- PIH
- post term babies
- rh problem (get baby out before more damage done)
- small babies
Side effects and contraindications of prostaglandins
- n/v, diarrhea
- asthma, glaucoma, heart probs
Augmentation
-crazy contractions, going to stop and try again
Pitocin
- contractions more painful
- bp may drop
- contractions & fetal distress
- uterine rupture
- water intoxication (like a antidiuretic)
- watch pt output
S/S of water intoxication
- headache
- vomiting
- seizure
- coma
Amniotomy
- breaking bag of water
- document what fluid looked like
First responsibility of Amniotomy
- Check the FHT
- Temp q 2 hours
- Minimal vaginal exams
- Documentation
First stage of labor
- Latent phase (0-3 cm dilated last 4-6 hr, contractions q5 min)
- Active phase (4 cm dilated, contraction harder & stronger)
- Transition phase (irritable, leg tremors, vomit)
Second stage of labor
- Period from full dilatation and cervical effacement to birth of the infant
- Pushing time (grunt)
Third stage of labor
- Placental separation
- Placental expulsion
- Getting ready to deliver placenta (should take 30-45 min, if longer could be placenta acreta)
Placental acreta
- Placenta has dug into wall of uterus
- Has to undergo surgery
Fourth stage of labor
postpartum, recover—>vs, check fundus
ask pt what they want done with placenta
placenta blood done for research, membranes can be used for burn victims
Nursing care: 1st stage
- Change positions (for back ache, and to prevent ulcers)
- Voiding and bladder care (if epidural needs catheter, if not KEEP EMPTY)
- Pain management (let her know meds are available)
- Do not let mother push during transitional phase (can tear cervix)
- Digestion slows down during labor (can give toast, cracker, broth)
Dysfunctional labor problems
- Prolonged latent phase (teach breathing exercise)
- Protracted active phase
- Prolonged descent (deceleration)
- Secondary arrest of dilation
- Fetal Distress
Nursing care: 2nd stage
- Preparing for birth
- Positioning for birth
- Pushing
- Perineal cleaning
- Episiotomy (midline or mediolateria)
- Birth
Cutting and clamping of cord
Premature or sick baby you want the cord to be a little longer (for iv)
Wartens jelly
Gushy stuff in cord
Interventions for dysfunctional labor 1 & 2
- Monitor for distress (Maternal/fetal)
- Assist with forceps, extractor, section
- Keep pts sugar up
Advantages of vacuum assist
- Little anesthesia
- Fewer lacerations
Disadvantages of vacuum assist
- Large caput (knot on head)
- Tentorial tears (put pressure & ice)
- Cervical bruising tear
- Cannot be used on premies (head too thin)
McRoberts
Pulling back on legs (opens pelvis)
Nursing Care: 3rd & 4th Stage
- Cutting, clamping and examination of the cord
- Oxytocin
- Placental delivery
- Perineal repair
- Assessment
- Aftercare
- Observer for complications
Non-pharmacological pain management during labor
- Positioning and Movement
- Breathing
- Music
- Relaxation
- Other attention-focusing strategies
- Guided imagery
- Massage and touch
- Guided imagery
- Hydrotherapy
- Heat/cold application
- Biofeedback, TENS, intradermal water block
- Accupressure/acupuncture
What can cause fetal dystocia?
- size, (esp head), macrosomia
- malpresentations
- malposition
- multiples
Fetal distress s/s
Decelerations, meconium stained fluids
Fetal distress tx
treat the cause –(? Overdue, Cord, placenta), with fluids, positioning, amniofusion, O2, Meds, delivery, C/S
IUGR
Intrauterine growth restriction
Precipitate labor
Labor that lasts less than 3 hr from the onset of contractions to time of birth
Inversion of the uterus
Uterus turns inside out after birth
labor augmentation
- ambulation
- hydrotherapy
- ROM
- nipple stimulation
- oxytocin infusion
Mechanisms of labor
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
