Labour and Birth Care Fundamentals Flashcards
Factors affecting labour: 5+1 “P”s
- Passenger (fetus and placenta)
- Passageway (bony pelvis and soft tissue)
- Powers (contractions and pushing)
- Position (client)
- Psychologic and People
Emotional Dystocia
• What’s happening in the mind is altering what is happening in the body
Tocophobia
- Fear of labour and contractions; often due to history of varied experiences and/or portrayal of scary stories; the way the media presents labour/birth
- Estimated ` in 10 experiences extreme tocophobia
Psychologic factors of labour and birth
Fear - Pain - Tension
- Moderate to severe anxiety
- Physiologically can have results
- Magnified pain experience can stall labour and decrease confidence
- Clients who come in with a very fixed mindset have a hard time adjusting to needed changes and adapting in situations
- Mind-body connection and tensing can change pain
- GOAL is to minimize or reduce catecholamine secretion
How client anxiety during labour affects the body
- Increases catecholamine secretion
Which causes
- Increased in muscle tension
- Decrease in uterine contractility (reduces blood flow; less oxytocin flow)
- Magnifies pain experience
Which
- Decreases confidence
- Decreases labour progress
How People affects labour and delivery
• Effective caregivers are: respectful, supportive, available, protective, encouraging, kind, patient, professional, calm, comforting, present
• 1:1 nursing care (goal)
• Companion of choice for labour support;
- Not the nurse – ideally not a family/friend, moderate amount of training in labour support and ideally can meet them before (doula); collaborative care and the dynamic/role of the nurse shifts
Factors that influence pain experience during labour and birth
Perception, interpretation and response to pain influenced by various factors:
• Physiologic – number of pain receptors
• Psychologic – expectations and pain thresholds
• Emotional – fatigue and sleep deprivation magnify pain
• Social – previous pain interactions in one’s life
• Cultural – pain perceptions in culture, previous interactions with pain
• Environmental – physical characteristics of one’s environments
Pain and satisfaction in the child birth experience
• Pain control does not equal a positive experience
• Satisfaction
- Caregiver attitudes and behaviours
- Quality of caregiver-client relationship
- Involvement in decision making
- Degree of control
Definition of a positive child birth experience
- Clinically and psychologically safe environment with continuity of practical and emotional support from a birth companion(s) and kind, technically competent clinical staff
- A sense of personal achievement and control through involvement in decision-making
- Frame of mind in which to approach
- Not just a technician for L&D; help guide them through it and make decision to ease their pain and create a positive experience
What is supportive care during labour
•“Non-medical are that is intended to ease a woman’s anxiety, discomfort, loneliness, or exhaustion, to help her draw on her own strengths , and to ensure that her needs and wishes are known and respected”
What does Supportive Care Look Like?
• Continuous presence of a supportive caregiver
• Includes:
- Physical comfort measures – coaching of position changes, reminding of drinking water, etc.
- Emotional support – reassurance, encouragement, praise
- Information and instruction
- Advocacy
- Support for Partner – need to remember partner and companion
Impact of labour support
Increased: • Positive ratings of birth experience • Feelings of competence, confidence • Length of breastfeeding • Maternal assessment of baby’s personality, competence and health
Decreased: • Epidural rate/usage • Use of forceps, vacuum • Analgesia/anesthesia use • Length of labour • Episiotomy rate • Caesarean birth • Postpartum depression
Barriers to supportive care during labour
- Inadequate staffing – no time; admin duties, relieve other nurses and multiple clients, breaks, the way staffing is done (static staffing)
- High tech environment
- Unnecessary medical interventions – routine use of IVs, electro-fetal monitoring that keeps people in bed; more challenging and time consuming to get them into different positions and techniques
- Lack of caregiver education and training
- Lack of management support
- Resistance – it’s hard work!
Passenger in labour
- Vertex presentation
- Depending on the angles, and the ability of the head to mold
- Breach presentations; wider diameters; many are born by C/S
- ECV: externally and physically change the position of the fetus; try and turn the baby
- Skull bone not ossified; can help (if needed) to overlap to accommodate the pelvis; called molding
- Capet; different from molding, it’s a cone shape of the head due to pressure
- Passenger includes the placenta
Passageway: Cervical effacement and dilation
- Cervix is a few cm wide and tight
- During labour it gets softer; it shortens and thins out before it begins to open
- Have to be dilated to 10cm before being able to push
- Palpating cervix; feel membranes; lip of cervix, head of fetus, what’s the baby’s position
Passageway: Station
• When the presenting part, its relationship to the ischial spine
• Palpating for the ischial spine
• Draw an imaginary line from one to the other; zero (0) station; there are cm above and below
- (+) number are below (0) and baby is coming out; (-) numbers are above (0) and baby is farther back
• The widest diameter of the presenting part (of the head) has reached zero station
• The widest part of the head has reached zero; then it is engaged
• Spines also means station = at spine means at zero station
• All based on palpation
Powers (involuntary): Contractions
- Menstrual cramps to tightening to contractions
- Other people can go straight to contractions
- Wave-like; pushes the baby down and pulls the lower part to the uterus and cervix out
- Don’t want labouring people of people past 20 weeks on their back; weight in the uterus causes pressure in the arteries, can cause hypotension and venous pooling
- Wedge client if they need to be on their back
- Some clients you can see contractions
- When EFM is on; assess fetal HR and uterine activity
What to assess contractions on
- Assessing contractions: the pacemaker is in the uterine fundus; intensity and duration of the contraction is palpable in the fundus
- Assessing: duration frequency, intensity
- Duration is how long the contraction lasts; beginning to end in secs
- Frequency is how often; beginning on one contraction to the beginning of the next contraction
- Intensity you let the client rank and palpation
Positions during labour
- Of the labouring client
- All upright positions; labour is about movement (with and in the labouring person’s body)
- Clients upright help with blood flow, reduced pain, perception of pain on back
- Also helps with the mechanics of labour
- Don’t have to be upright all the time; all about positions changes
Examples:
- Walking
- Sitting/leaning
- Tailor sitting
- Semi-recumbent
- Hands and knees
- Standing
- Squatting
- Kneeling and leaning forward with support
Pre-labour vs Labour
Pre-labour: • Irregular uterine activity • Stop with walking or position change • Felt it in back, all over abdomen • Can be stopped with comfort measures • Cervix – may be soft, no significant change in effacement/dilation • No bloody show
Labour:
• Regular uterine activity
• Stronger, longer, closer together
• Become more intense with walking
• Felt in lower back, lower abdomen, don’t stop with rest
• Cervix – cervical change (softening, effacement, dilation)
• + bloody show
Amniotic membranes
- The amniotic membranes rupturing is “water breaking”
- Can released prostaglandins and help progress labour
- ROM; rupture of membranes
- SROM; spontaneous rupturing of membranes
- PROM; premature rupture of membrane
- PPROM; prolonged premature rupture of membranes
- AROM (ARM); artificial rupture of membranes
Assessment of amniotic membranes: COAT
- Colour; clear, meconium stains
- Odour; raw chicken smell, foul smelling (due to infection)
- Amount; copious amounts, small amounts
- Time; what time did the membranes rupture; the longer the membranes are ruptured the increased risk for uterine infection
• Fetal heart fate; one full minute; listening as soon as membranes rupture; ensure cord is okay place
Ferning test
• Ferning tests; put amniotic fluid under slide and dried; creates ferning pattern
Nitrazine test
• + Nitrazine; strip test to determine if membranes have ruptured, interacts positively with membranes
GBS and labour/birth
- Group B Streptococcus (GBS); 35-37 weeks GBS swab done; put on GBS protocol, given IV antibiotics to cover the baby (2 doses minimum 4 hrs apart)
- GBS an cause the baby to have mengitis, sepsis, early and late signs
Fetal meconium aspiration
• Meconium in amniotic fluids; greenish ting; due to post date or fetal distress; fetus can aspirate meconium and can be very dangerous
Stages of labour
• 1st stage: onset of uterine activity to complete cervical effacement and dilation
- 2 phases: latent and active
• 2nd stage: full dilation to birth of fetus
• 3rd stage: birth if fetus to birth of placenta
• 4th stage: 1-2 hours post birth
Latent 1st stage of labour
• Cervix Dilation; 0-3cm • Cervix Effacement; <1cm (or 75%) • Duration; 6-8hrs • Contractions: - Strength; mild-moderate - Rhythm; irregular - Frequency; q5-30mins - Duration 30-45sec • Fetal Descent; 0 to -2 • Show - Colour; pink - Amount; scant
Active 1st sage of labour
• Cervix Dilation; 4-10cm • Cervix Effacement; thin (75-100%) • Contractions: - Strength; moderate-strong - Rhythm; regular - Frequency; q2-5mins - Duration; 40-90sec • Fetal Descent; varies • Show: - Colour; pink-bloody - Amount; scant-copious
Client responses to 1st stage of labour
- Latent: alert, excites; mildly anxious; ‘settles in’; talkative; open to instructions and able to follow them, coping
- Active: absorbed in serious work of labour; turns inward; more intense; cannot converse during contractions; increased dependency and apprehension; decreased ability to cope and communicate
- Irritable; doubt/fear; unable to follow instructions; exhibits hysteria; fatigue
- Every labour is a unique experience; but there are many commonalities to how people respond
- Many people with an epidural will not experience these
RN role in 1st sage of labour
• SUPPORTIVE CARE including Simkin’s assessing and assisting
• Review admission data
• Nursing assessment: physical, emotional, psychosocial, cultural
• Fetal assessment
• Ongoing monitoring
• Perform interventions (including medications)
• Documentation
• Coordination
- In latent phase; get to know the patient before things get crazy; so you can understand how they will respond and what will will/won’t work
- Remember: we also have a client we can’t see
Non-pharmacological pain management options for labour
- Breathing techniques
- Imagery and visualization
- Music
- Touch and massage
- Effleurage and counter-pressure
- Energy work
- Hydrotherapy
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Acupressure and acupuncture
- Heat/cold therapy
- Hypnosis
- Biofeedback
- Aromatherapy
- Intradermal water block
- Physical care measures
- Position changes
- Rapport, feedback
- Encouragement, validation
- Take charge routine (Simkin, 2002)
- Anticipatory guidance
- Active listening
NURSING GOAL IS TO MAXIMIZE COPING
Pharmacologic pain management options for labour
- Sedatives
- Analgesia; goes IM into bloodstream, asses the blood fetal barrier, cause drowsiness for 2-3hr; not administered right before birth to do respiratory depression side effect
Anesthesia:
- Local; freezing for suturing
- Pudendal nerve block
- Epidural block
- Spinal block
- Combined spinal.epidural (CSE)
- Nitrous oxide; help reduce perception of pain
- General anesthesia; only used for C/S is there is contraindication to epidural or spinal insertion or STAT C/S
RN role for pharmacologic pain management
- What do they know, where are the gaps (if any) so the holes can be filled
- See the birth plan, advocate for their choice
- Bladder functions especially important for epidural
- Fetal heart rate ALWAYS
- Assess return of function while epidural wears off
Epidurals and Spinal Blocks
- Epidural goes into the epidural space (above the dura mater); blind procedure; regional block – block pain sensation but not pressure sensation
- Spinal block goes deeper in, into the spinal fluid; solid block, higher concentration and wears off quickly
- Because hypotension is the #1 side effect, IV is always given for an epidural; IV rate can be increased to increase circulatory volume and increase FHR
- CBC; epidural will not be inserted is patient is not clotting properly, has low levels of platelets
- Epidural usually placed between L3-L5
- Pruritus (itchiness) is due to the fentanyl
- Post-dural puncture headache is a rare complication
2nd stage of labour
• Full cervical dilation to the birth of the fetus
• Duration:
- primip 50-60 mins average
- multip 20-30 mins average
- Primary vs secondary powers
- 2 phases: passive and active
- Open vs closed glottis pushing
Client responses to 2nd stage of labour
- Passive; rest, calm, passive fetal descent “labouring down”
- Descent; increased urge to bear down, intent on work of pushing, intense pain, ‘ring of fire’, excitement and relief with birth of head
RN role in 2nd stage of labour
- Assess signs of full dilation
- 1:1 nursing care
- Supportive care
- Hygiene, comfort measures
- Ongoing assessment and monitoring of client and fetus
- Documentation
- Coordination of care
- Assist birth attendant
3rd stage of labour
• Birth of fetus to placental separation and expulsion
• Duration; few minutes to 1 hour
• Separation signs:
- Change in uterine shape (discoid to globular)
- Sudden gush of dark blood
- Lengthening of umbilical cord
• The increased length of the 3t stage increases the risk of PPH
• Evidence based active management of 3rd stage
Client responses to 3rd stage of labour
- Surge of energy despite being very exhausted
- Varying emotions
- Some discomfort with placental separation process
RN role during 3rd stage of labour
- 1:1 nursing care
- q15mins monitoring
- Promote and facilitate immediate/early bonding
- Assist birth attendant
- Explain procedures
- Documentation
4th stage of labour
• After birth to 30 days postpartum
C/S indications during labour
- Malpresentations; feet first, shoulders first, etc.
- CPD (Cephalo-Pelvic Disproportion); head too bid to fit through pelvis
- Placental abnormalities; placenta abrupts, abnormal implants
- Labour complications; dystocia (labour stops progressing), anything that causes fetal distress
- Fetal compromise
- Medical factors; complications in labour, preeccamplysa, previous gyne procedures in uterus
- Other
RN role C/S intraoperative
- PreOP prep
- Circulating vs scrub nurse
- Safety checks
- Assist with pain management
- Care coordination
- Documentation
- Support person
- Newborn care monitoring
RN role C/S recovery room (PACU)
- Assessment and monitoring q15mins until stable and/or recovered from anesthesia
- Postpartum physical assessment + O2 sat, LOC, colour, I&Os, level of block
- Newborn vitals and care
- Assist with feeding and S2S
- Facilitate bonding
- Care coordination
Potential adverse effects of epidural and spinal anaesthesia
- Hypotension
- Local anaesthetic toxicity
- Lightheadedness
- Dizziness
- Tinnitus (ringing in the ears)
- Metallic taste
- Numbness of the tongue and mouth
- Bizarre behaviour
- Slurred speech
- Convulsions
- Loss of consciousness
- High or total spinal anasthesia
- Fever
- Urinary retention
- Pruritus (itching)
- Limited movement
- Longer 2nd stage labour
- Increased use of oxytocin
- Increased likelihood of forceps or vacuum assisted birth
- Postdural puncture headache
