Labour & Birth Care Fundamentals Flashcards
What are the 5+1 P’s that affect labour?
Passenger (fetus and placenta) Passageway (bony pelvis and soft tissue) Powers (contractions and pushing) Position (client's position) Psychologic \+ People
Emotional Dystocia
psychological stress that can cause labour to stall or slow down
- extreme fear of labour pain, not feeling safe, lack of privacy, trauma from prior sexual abuse
Tocophobia
Intense fear of pregnancy and childbirth
1 in 10 people
How does anxiety affect labour?
Anxiety causes increased secretion of catecholamine. Muscles become tense - decreased blood flow and oxygen flow, affecting uterine contractility.
What are the 3 elements in the mind-body connection cycle?
Fear
Tension
Pain
Explain the 6th P: People
An effective and trained caregiver that supports the birth parent (such as doula or midwife)
OR
One to one nursing care
What are some factors that affect one’s pain experience?
- Physiologic (health condition or variation in pain tolerance)
- Psychologic (abuse or past experience)
- Emotional (sleep deprivation or fatigue)
- Social (other’s experience?)
- Cultural (expression and understanding of pain)
- Environmental (mood/atmosphere of birthing setting)
Sources of labour pain
a. uterine contraction
b. back (baby’s head putting pressure)
c. pelvic nerve pressure
d. stretching of perineum
What contributes to satisfaction or a positive experience?
- caregiver attitudes and behaviour
- quality of caregiver-client relationship
- involvement in decision making
- degree of control
How does WHO define “Positive Childbirth Experience”
…one that fulfils or exceeds woman’s personal expectations
- giving birth to healthy baby
- safe environment
- continuity of practical and emotional support
- kind and competent companion/staff
- sense of achievement and control
What is Supportive Care?
“Non-medical care 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 he needs and wishes are known and respected.”
What does Supportive Care look like?
- continuous presence of caregiver
- physical comfort measures
- emotional support (encouragement)
- information and instruction
- advocacy
- support for partner
Labour Support increases..
a. positive ratings of birth experience
b. feelings of competence, confidence
c. length of breastfeeding
d. maternal assessment of baby’s personality, competence and health
Labour Support decreases..
a. epidural rate/usage
b. use of assistive devices (forceps, vacuum)
c. analgesia/anesthesia use
d. length of labour
e. episiotomy rate
f. caesarean birth
g. postpartum depression
What are some barriers to Supportive Care?
a. inadequate staffing
b. high tech environment (reduced interaction?)
c. unnecessary medical interventions
d. lack of caregiver education and training
e. lack of management support
f. resistance from staff
Moulding
overlap of skull bones to accommodate fitting through the birth canal, causes cone shaped head
Breech presentation
baby’s buttocks and/or feet positioned to be delivered first (sacrum)
Cephalic presentation
head first enters pelvic inlet (occiput)
Shoulder presentation
Scapula (shoulder bone) lies closest to the cervix
Cervical effacement
Shortening and thinning of the cervix during the first stage of labour
Dilation
Enlargement or widening of the cervical opening and the cervical canal that occurs once labour has begun
What does vaginal assessment reveal?
a. dilation and effacement
b. status of membrane
c. fetal positioning
Station
- relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines
- a measure of the degree of descent of the presenting part of the fetus
Engagement
when the largest transverse diameter of the presenting part has passed through the maternal pelvic brim (station 0)
- often occurs in the weeks just before labour begins
Gate control theory of pain
non-painful input closes the nerve gates to painful input, which prevents pain sensation from travelling to the CNS
Contractions
Involuntary powers
- wavelike
- measured by duration, frequency and intensity
Why shouldn’t labouring people be on their back?
- venous return issue
- hypotension in the adult (decreased cardiac output from compressed major vessels)
- fetal distress
What positions are recommended and why?
upright positions (walking, sitting, kneeling or squatting)
- promote the descent of fetus
- stronger contractions
- more efficient in effacing and dilating the cervix
- shorter labour
- increased cardiac output
- prevent compression of vessels
What is the significance of positions in labour?
Frequent position changes relieve fatigue, increase comfort and improve circulation
Occipitoposterior (OP) position
when the back of baby’s head is against the mother’s back
What is the best baby position for birth?
cephalic presentation (head down) with back of head towards tummy (anterior)
Symptoms of “Prelabour”
a. Irregular uterine activity
b. Stops with walking or position change
c. feld in back and all over abdomen (but not cervix)
d. can be stopped with comfort measures
e. no effacement or dilation of cervix
f. no bloody show
Symptoms of “Labour”
a. regular uterine activity
b. stronger, longer and closer together
c. become more intense with walking
d. felt in lower back, lower abdomen
e. cervical change (soften, effacement, dilation)
f. bloody show
SROM
AROM
PROM
PPROM
Spontaneous Rupture of Membrane
Artificial ROM
Premature ROM
Preterm Premature ROM
Assessment of Amniotic Fluid
COAT
Colour (clear)
Odour (no strong odour)
Amount (1000ml)
Time
Fetal heart rate needs to be monitored closely following ROM
Nitrazine test
Strip test using vaginal fluid
BLUE strip means:
fluid is alkaline, ph greater than 6
- membranes have likely ruptured
Ferning test
detection of “fern like” characteristics
- vaginal secretion dried on a glass slide and viewed under microscope
- ferning indicates ROM
Group B Streptococcus (GBS) test
- GBS is considered normal vaginal flora but can cause infection
- usually done between 35-37 weeks
- GBS swab of vagina and rectum
- if positive, initiate GBS protocol: IV antibody prophylaxis (ampicillin) at least 2 doses, 4 hours apart before ROM
Stages of Labour
1st Stage: onset of uterine activity to complete cervical effacement and dilation
2nd Stage: full dilation to birth of fetus
3rd Stage: birth of fetus to birth of placenta
4th Stage: 1 to 2 hours post birth (recovery)
Described the 1st Stage of Labour
a. Latent
- 0-3 cm
- 6-8 hours
- mild-mod contractions q5-30min
- brownish pink show
- excited, alert, coping
b. Active
- 4-7 cm
- 3-6 hours
- mod-strong contractions q2-5min
- pink, bloody mucus
- absorbed, more intense, dependent, irritable
average 14-16 hours in 1st stage
Hyperesthesia
abnormal increase in sensitivity to stimuli and touch
What nursing interventions are appropriate to support 1st stage of labour?
- review admission data
- assessment: physical, emotional, psychosocial, cultural
- fetal assessment
- ongoing monitoring
- perform interventions (medications)
- documentation
- coordination of care
What are some non-pharmacological pain management options?
a. relaxation techniques (BEST!)
b. touch and massage
c. music
d. hydrotherapy
e. position change
f. focus on focal point
g. encouragement and validation
The nursing goal of pain management is to..
maximize coping
Pharmacologic Pain Management options
a. sedatives
b. analgesia
c. anesthesia
(local, epidural block, spinal block, nitrous oxide, general anesthesia)
When might sedation be used during labour?
on occasion if patient is sleep deprived but not advanced in labour
What are the effects of analgesics?
Takes some pain away but may make patient drowsy
- may cause respiration depression when given within 2-3 hours of 2nd stage of labour
When might general anesthesia be used during labour?
typically for c-section ONLY when epidural is contraindicated or no time for epidural
(family members are not allowed to accompany in this case)
What is the nurse’s role in pharmacologic pain management?
- inform and facilitate informed decision making
- advocate
- monitor and manage side effects
- administer if indicated
- bladder function
- assist anesthesiologist
- ensure safety
- document
What is the nurse assessing when pharmaco pain management therapies are given?
a. vital signs
b. FHR
c. contractions and labour progress
d. response and pain level
e. sensory and motor function
f. return of sensory and motor function when d/c
Signs that suggest onset of 2nd Stage
- urge to push or feeling need to have a bowel movement
- an episode of vomiting
- increase bloody show
- increased restlessness
- involuntary bearing down efforts
- inability to feel cervix during vaginal examination
Describe the interventions for 2nd Stage of Labour
a. Passive phase
- encourage relaxation to conserve energy
- position change, ambulation, promote progress of fetal descent
b. Active phase
- relax between contractions
- cleanse perineum promptly if fecal material is expelled
- provide emotional support and encouragement
- keep woman informed about progress
- coach open glottis pushing
Timing of pushing
- bearing-down sensations
- push should be minimized before cervix is fully dilated to avoid tear/rip of the cervix
- pant or pant-blow may be practiced to resist the urge to push
Open-glottis pushing
push as she feels like pushing (instinctive, spontaneous push)
not holding your breath
Closed-glottis pushing
Giving a prolonged push on command
- breath-holding, closing glottis, push while counting to 10
usually during a contraction
What is the average duration of 2nd stage of labour?
Primip 50-60mins
Multip 20-30mins
Spinal block
local anesthetic and/or opiod is injected into the subarachnoid space (puncturing dura mater) using a catheter secured on the back
- anaesthestic solution mixes with cerebrospinal fluid
Epidural block
local anesthetic and/or opiod is injected into the EPIDURAL space using a catheter
- most effective pain-relief method
- between 4th and 5th lumbar vertebrae
What are some possible side effects of epidural anesthesia?
- hypotension
- pruritus
- nausea
- postdural puncture headache
- headache caused by loss of spinal fluid
What else is important to know about epidurals?
a. does not go into bloodstream
b. cannot be done if client does not have normal clotting
c. best done at 4 cm dilation with regular contractions
d. does not block pressure sensation
Ferguson reflex
Area in uterus that causes more contractions when pressure is applied
Describe the 3rd Stage of Labour
- birth of fetus to placenta separation and expulsion
- typically lasts 5-10 mins but can last up to an hour
- separation signs include change in uterine shape, sudden gush of dark blood and lengthening of umbilical cord
- suturing of lacerations at this time
Increase in length of 3rd stage can cause..
Increase in risk of hemorrhage
Client’s responses during 3rd Stage of Labour
- surge of energy despite being exhausted
- varying emotions
- some discomfort with placental separation process
What nursing interventions take place during 3rd Stage of Labour?
a. one on one nursing care
b. q15min monitoring
c. promote and facilitate bonding
d. assist birth attendant
e. explain procedures
f. documentation
What are some active management procedures during 3rd stage?
- administration of oxytocin
- clamping and cutting of umbilical cord within 3 minutes after birth
Describe the 4th Stage of Labour
- 1 to 2 hours after birth
- frequent assessment q15min for 1 hour
Assessment during 4th Stage of Labour
a. BP (q15min)
b. pulse (q15min)
c. Temp (beginning and end of 1st hour)
d. fundus
e. lochia
f. perineum (observe source of bleeding)
- REEDA
- presence of hemorrhoids
C/S indications
a. malpresentations
b. CPD (cephalo-pelvic disproportion)
c. placental abnormalities
d. labour complications
e. fetal compromise (fetal distress)
f. medical factors
Role of nurse during C/S
a. pre-op prep
b. safety checks
c. pain management
d. care coordination
e. documentation
f. support person
g. newborn care and monitoring
What nursing interventions take place after C/S?
a. monitoring q15min until stable or recovered from anesthesia
b. postpartum assessment (+O2 stat, LOC, colour, I&Os, level of bock)
c. newborn vitals and care
d. feeding and S2s
e. facilitate bonding
f. care coordination
PACU
Post Anaesthetic Care Unit
Describe the “Transition” stage in the 1st Stage of Labour (prior to 2016)
a. 8-10cm cervix dilation
b. usually lasts 20-40 mins
c. strong, regular contractions q2-3 mins
d. contractions lasts 45-90 sec
- bloody mucus, copious amount
