NURSING CARE DURING LABOR & BIRTH Flashcards
Intrapartum Assessment:
(PEG FARM. PLBFLP)
- *Prenatal Care
- *EDD (estimated date of delivery)
- *GTPAL (grativa, term, para/preterm,abortions, live children)
— *Grativa: how many times she was pregnant
. - *Fetal Evaluation (know position)
- *Allergies (med/ anesthesia)
- Recent Illness
- Medications
. - Pregnancy History
- Labor status
- Birth Plan
- *Food Intake (NPO)
- *Labor Status (true/ false)
- Physical Examination
Leoplod’s Maneuvers:
- 1: is feeling for the top of the fundus. Feeling squishy, or firm and round like head.
- 2: feeling the sides. I feel a smooth round area, which is the back, if it is bumpy, then it may be the legs
- 3: feeling near the symphysis pubis for the presenting part. Feeling if it is the head or the buttocks.
- 4: feeling, if they are engaged at the ischial spine. If you can’t bring your fingertips together, the baby is not engaged.
Vaginal Examination:
- Determine whether the membranes have ruptured
- Determine cervical dilation and effacement
- Determine fetal presentation, position, station
Amniotomy: Artificial Rupture of membrane:
Indications
- Induce labor
- Augment labor (speed up labor)
- Allow internal fetal monitoring
Amniotomy: Artificial Rupture of membrane: Risks
- Prolapse cord
- Infection (we want to deliver within 24 hours of ruptured membranes) the infection can pass to the fetus
- Abruptio placenta
Comfort Measures:
- Ice Chips
- Cool washcloths
- Lighting, temperature, positioning
Positions for First stage:
- Standing/ walking:
- Sitting upright:
- Sitting, Leaning forward with support:
- Semisitting
- Side lying:
- Kneeling, Leaning Forward with support:
- Hands and knees:
Standing/ walking: Advantages
augments/speeds up labor
- Add to gravity to force of contractions to promote fetal descent
- Contractions are less comfortable and more efficient
- *Variation: standing, leaning forward with support, reduces back pain, because fetus falls forward, away from sacral promontory
Standing/ walking: Disadvantages
- Tiring over long periods
- Continuous electronic fetal monitoring is not possible without telemetry if a woman is walking in the hall
Standing/ walking: Nursing Implications:
- If the woman has IV fluid running, give her a rolling pole
- Encourage her to alternate walking with other positions whenever she tries or desires to do so
- Remind the woman and her partner when she should return to the labor area for evaluation of the fetal heart rate, and her labor status
Sitting upright: Advantages
Uses gravity to aid fetal descent
- Uses gravity to aid fetal descent
- Can be done when sitting on the side of bed, in a chair, or on the toilet
- Can be used with continuous fetal monitoring
- Avoids supine hypotension
Sitting upright: Disadvantages
- May increase suprapubic discomfort
- Contractions are the most efficient when the woman alternates sitting with other positions
Sitting upright: Nursing Implications:
- A rocking chair is soothing
- Place pillow on a chair with a disposable underpad over the pillow to absorb secretions
- Use pillows or a footstool to keep a short woman’s legs from dangling
- Encourage the woman to alternate positions periodically.
— For example, she can alternate walking with sitting or sitting with side lying
Sitting, Leaning forward with support: Advantages
helps with back pain
- Same as for sitting
- Reduce back pain because fetus falls forward, away from sacral promontory
- Partner or nurse can rub back or provide a sacral pressure to relieve back pain
Sitting, Leaning forward with support: Disadvantages
Same as for sitting
Sitting, Leaning forward with support: Nursing Implications:
Same as for sitting
Semisitting: Advantages
- Same as for sitting
- Aligns, long access of uterus, with pelvic inlet, which applies contraction force in the most efficient direction through pelvis
Semisitting: Disadvantages
- Same as for sitting
- Does not reduce pain as well as forward leaning positions
Semisitting: Nursing Implications:
- Same as for sitting
- Raise bed head of bed to 30°- 45° angle
- Encourage the woman to use sitting (leaning forward) or side lying position if she has back pain so the caregiver can rub her back or apply sacral pressure
Side lying: Advantages
promotes placental blood flow
- It is a restful position
- Prevents supine, hypotension and promotes placental blood flow
- Promotes efficient contractions, although they may be less frequent then with other positions
- Can be used with continuous fetal monitoring
Side lying: Disadvantages
Does not use gravity to aid fetal dissent
Side lying: Nursing Implications:
- Teach the woman and her partner, that, although the contractions are less frequent, they are more effective
- This position offers a break from more tiring positions
- Use pillows for support and to prevent pressure: at her back, under her superior arm, and between her knees
- Use disposable underpads to protect the pillow between the woman’s knees from secretions
- Some women like to put their superior leg on the bed rail
- If the woman wants this variation, pad, the bed rail with a blanket to prevent pressure
- If she wants to remain recumbent, she should use this position to promote placental blood flow
Kneeling, Leaning Forward with support: Advantages
- Reduce back pain because fetus falls forward away from sacral promontory
- Add gravity to force of contractions to promote fetal descent
- Can be used with continuous fetal monitoring
- Caregivers can rub her back and apply sacral pressure
- Promotes normal mechanisms of birth
Kneeling, Leaning Forward with support: Disadvantages
- Knees may become tired or uncomfortable
- Tiring if used for long periods
Kneeling, Leaning Forward with support: Nursing Implications:
- Raise the head of the bed, and have the woman face the head of the bed while she is on her knees
- Another method is for the partner to sit in a chair, with a woman, kneeling in front, facing her partner, and leaning forward on him or her for support
- Use pillow under the knees and in front of the woman’s chest as needed for comfort
- Encourage her to change positions if she becomes tired
Hands and knees: Advantages
Helps relieve cord compression (decreases variability in FHR monitor)
- *Helps relieve cord compression (decreases variability in FHR monitor)
= Reduce back pain because of the fetus falls forward, away from the sacral promontory
- Promotes normal mechanisms of birth
- The woman can use pelvic rocking to decrease back pain
- Caregivers can rub the woman’s back or reply, sacral pressure easily
Hands and knees: Disadvantages
- The woman’s hands (especially wrists) and knees can become uncomfortable
- Tiring when used for a long time
- Some women are embarrassed to use this position
Hands and knees: Nursing Implications:
- Encourage the woman to change to less tiring positions occasionally
- Ensure privacy when encouraging the reluctant woman to try this position if she has back pain
- A second hospital gown with the opening in front covers her back and hips, but may be too warm
— A variation is for the mother to kneel and lean forward against a beanbag or the side of the bed. This variation reduces some of the strain on the wrists and hands.
Positions for pushing in second stage:
Squatting
Semi-sitting:
Side lying:
standing squat:
this position may be tiring and access to the woman’s perineum is difficult. Because the infant could fall into the ground, if birth occurs rapidly. Provide padding under the mothers feet. Gravity aids, fetal descent.
Hands and knees squat:
- advantages and disadvantages are similar to those during the first stage of labor.
- In addition, caregivers must reorient themselves because the landmarks are upside down from their usual perspective
Squatting: Advantages
- Add to gravity to force of contractions to promote fetal descent
- Increases dimensions of pelvis slightly
- Promotes effective, pushing effort in the second stage
- Caregivers can rub back or provide sacral pressure
Squatting: Disadvantages
- Knees and hips may become uncomfortable because of Prolonged flection
- Tiring over a long time
Squatting: Nursing implications
- Provide support with a squat bar, attached to the bed or by two people standing on each side of the woman
- If she becomes tired, or between contractions, she can lean back into the sitting position
- Variation: have the woman squat beside the bed as she pushes
Semi-sitting:
- Many women prefer this, because they have the security of a back rest
- It is also familiar to caregivers and allows easy observation of the perineum
- Elevate the woman’s back at least 30° - 45° angle so that gravity aids fetal descent.
- The woman pulls on her flexed knees (behind or in front of them) as she pushes
- She should keep her head flexed and her back in a C curve
Side lying:
- The woman flexes her chin on her chest and curls around her uterus as she pushes
- She pulls on her flexed knees or the knee of the superior leg as she pushes
Self Care during Labor:
- Providing information about the nature of the discomfort that will occur during labor is important
- Supportive Relaxation Techniques
- Patterned-Paced Breathing (helps to prevent hyperventilation)
- Hyperventilation prevention:
— S/S: numbness, spasms, dizziness, syncope)
Induction of Labor:
Bishop score:
to assess cervical favorability (readiness)
Bishop score: cervix
1st column
Position
Consistency
Effacement
Dilation
Station
Bishop score: position
- 0: posterior
- 1: mid position
- 2: anterior
- 3: - blank-
Bishop Score:
Consistency
- 0: firm
- 1: medium
- 2: soft
- 3: - blank-
Bishop Score:
Effacement
- 0: 0-30%
- 1: 30-50%
- 2: 60-70%
- 3: >80%
Bishop Score: Dilation
- 0: closed
- 1: 1-2 cm
- 2: 3-4 cm
- 3: >5 cm
Bishop Score: Station
- 0: -3
- 1: -2
- 2: -1
- 3: +1,+2
Bishop Score modifiers:
Add 1 point for:
- Pre-eclampsia
- each previous vaginal delivery
.
Subtract 1 point for:
- Post date pregnancy
- Nulliparity (no previous vaginal deliveries)
- PPROM (premature preterm rupture of membranes)
Cervical Ripening: Prostaglandin agents:
- Dinoprostone gel or insert.
- Misoprostol- Cytotec
— **major side effect: Uterine hyperstimulation (ineffective contractions, decreased 02 to fetus, may cause uterus to rupture)
Induction of labor with Pitocin/oxytocin
- Infuse as a piggyback and titrate
- *Monitor FHR and uterine activity.
- If non-reassuring FHR or uterine hypertonicity (overstimulation of the uterus):
— Stop infusion
— flush with isotonic solution
— position mother in side lying position
— administer O2 8-10L/min via mask
Induction and Augmentation of Labor with Pitocin: Risks
- Hypertonic uterine activity
- Uterine rupture
- Maternal water intoxication
- Greater risk for chorioamnionitis (infection of the uterus)
- Greater risk for c-section (cesarean birth)
- Causes hypotension: give mom a 1L bonus prior
- Also, works like antidiuretic hormone and causes water intoxication overtime; it causes water retention and hypertension.
— Side effect of water intoxication (It is a side effect of a side effect not a side effect of Pitocin)
Version:
changing the position of the fetus
External Version: indications:
- *Change the fetal position from a breech, shoulder (transverse lie), or oblique presentation to cephalic
- *Done in the last trimester (37 weeks)
- *Must do it before engagement
- Ensure mom has IV access!!!
Internal Version: indications:
- Change the position of a second twin in a vaginal birth
- Done during labor
Version: Contraindications:
many contraindications, so this is a last resort. Must have a huge benefit to be done.
- Uterine malformations
- Previous cesarean
- Fetal size ≥4000 g
- Cephalopelvic disproportion
- Multifetal gestation
- Oligohydramnios
- Ruptured membranes
- Cord around the fetal body or neck (nuchal cord)
- Uteroplacental insufficiency
- Engagement of the fetal head
- Placenta previa
Version: Risks
- Few risks to the woman are present.
- Few serious fetal risks exist.
- Fetus may become entangled in the umbilical cord.
- Abruptio placentae may occur. (Placenta comes apart from the uterus prematurely)
- Mixing of fetal and maternal blood
Assistive Vaginal Delivery: Forceps or Vacuum
Indications
- Prolonged second stage of labor
- Exhaustion
- If mom has heart disease
- Non-reassuring FHR
Assistive Vaginal Delivery: Forceps or Vacuum
Preparation
- *Empty bladder
- Cervix completely dilated and membrane ruptured
- Adequate anesthesia
Assistive Vaginal Delivery: Forceps or Vacuum
Contraindications
- Cesarean birth (if it is preferred)
- Severe fetal compromise
- Acute maternal conditions
- High fetal station
- Cephalopelvic disproportion
Forceps: issues
less commonly used causes bruising and facial nerve damage
Vacuum
more commonly used
Episiotomy
making a cut to increase the size of the vaginal opening
Episiotomy indications:
- Shoulder dystocia (shoulders get stuck)
- Vacuum or forceps-assisted births
- Face presentation
- Preterm fetus
Median or Midline episiotomy: advantages
- Minimal blood loss
- Neat healing with a little scarring
- Less postpartum pain than the medial lateral episiotomy
Median or Midline episiotomy: disadvantages
- An added laceration may extend the median episiotomy into the anal sphincter
- Limited enlargement of the vaginal opening, because peroneal length is limited by the anal sphincter
Mediolateral episiotomy: advantages
- More enlargement of the vaginal opening
- Little risk that the episiotomy will extend into the anus
Mediolateral episiotomy: disadvantages
- More blood loss
- Increased postpartum pain
- More scarring and irregularity in the healed scar
- Prolonged dyspareunia (painful intercourse)
Cesarean Birth: Indications
- *Dystocia (difficult labor/delivery)
- *Cephalopelvic (fetopelvic) disproportion
- Hypertension
- Maternal diseases (heart disease)
- Active genital herpes
- Previous C-Section
- Some previous uterine surgical procedures
— Classic cesarean incision
— Removal of fibroid tumors - Persistent nonreassuring FHR patterns
- Prolapsed umbilical cord
- Fetal malpresentations (breech)
- Hemorrhagic conditions
Low Traverse: C-section incision
Advantages
- Unlikely to ruptured during a subsequent birth
- Makes VBAC possible for subsequent pregnancy
- Less blood loss
- Easy to repair
- Less adhesion formation
Low Traverse: C-section incision
Disadvantages
Limited ability to extend laterally to enlarge incision
Low Vertical: C-section incision
Advantages
Can be extended upward to make larger incision if needed
Low Vertical: C-section incision
Disadvantages
- Slightly more likely to rupture during a subsequent birth
- A tear may extend the incision downward into the cervix
Classic: C-section incision
Advantages
- May be the only choice in these situations:
— Implantation of a placenta previa on the lower anterior uterine wall
— Presence of dense adhesions from previous surgery
— Transverse lie of a large fetus with the shoulder impacted in the mothers pelvis
Classic: C-section incision
Disadvantages
- Most likely of the uterine incisions to rupture during a subsequent birth
- Eliminates VBAC as an option for birth of a subsequent infant
