Process of Labor Flashcards
Theories of Onset Labor - Maternal Factors
Stretching of uterine muscles
Estrogen/Progesterone changes
Oxytocin (“Love” hormone)
Release of prostaglandins
Theories of Onset Labor - Fetal Factors
- Fetal cortisol changes
• Shunts blood away from the uterus causing the uterus to contract and become irritable
• Increases RR & HR - Placenta ages
- Prostaglandins increase causing contractions
Signs of Impending Labor
Lightening Increased Vaginal D/C Increased Energy GI Symptoms (Diarrhea) Cervical Change ROM Lower Back Pain Weight loss Uterine Contractions
True Labor
- Contractions bring about changes in cervical effacement and dilation
- Regular contractions increase in frequency and intensity
- Continues despite comfort measures
- Cervix: moves to anterior position; bloody show
False Labor
- Irregular contractions with little or no cervical changes
- Decrease in frequency, duration, and intensity with walking or position changes
- Hydration or sedation slows/stops contractions
Stages of Labor
First stage – 3 parts: Latent, Active, Transition Phase
Second stage – delivery of baby
Third stage – delivery of placenta
Fourth stage – recovery
Latent Phase
Primip = 9 – 19 hours Multip = 6 – 14 hours Cervix: •effacing •dilating from 0 cm to 4 cm Contractions: •Frequency: 5 – 15 minutes •Duration: 10 – 30 seconds •Intensity: mild/bearable Bloody show occurs with cervical change Membrane usually intact, but can rupture
Latent Phase Characteristics
Cramps, backache, talkative and eager
Latent Phase - Nursing Interventions
Assessment:
o VS q1-2 hrs
o Assess cervical changes by SVE
o Assess FHR and UC q30 minutes
o Ascertain presence of blood show and ROM
Encourage activity
o Helps in fetal placement and cervical change
Encourage controlled breathing
Distraction activities
Position changes (off patient’s back) and ambulation
Active Phase
Primip: 5 hours, Multip: 2 – 3 hours Cervix: • Effacing, • Dilating from 4 cm to 7 cm Contractions: • Frequency: 3–5 min • Duration: 30–45 sec • Intensity: mod/strong • More D/C or blood show ROM or still intact
Active Phase Characteristics
- rapid dilation and effacement
- some fetal descent
- feelings of hopelessness
- anxiety and restlessness increase as contractions grow stronger
Active Phase Interventions
Assessment: o VS q1-2 hrs o Assess cervical changes by SVE PRN o Assess FHR and UC q15-30 minutes o Ascertain presence of blood show and ROM Encourage controlled breathing Distraction activities (back rub) Position changes (off patient’s back) and ambulation
Transition Phase
Primip: average 4 hours Multip: average 1 hour Cervix: • Complete effacement • Dilation from 7 cm to 10 cm Contractions: • Frequency: 1–2 min • Duration: 40–60min • Intensity: strong • Heavy blood show ROM
Transition Phase Characteristics
- tired
- restlessness
- irritable
- feeling out of control “cannot continue”
- N/V
- urge to push
Transition phase Nursing Interventions
Assessment: o VS q1 hrs o Assess cervical changes and fetal position by SVE o Assess FHR and UC q15 minutes o Ascertain presence of blood show and ROM o Check bladder distention Encourage controlled breathing Reassurance Position changes (off patient’s back)
Second Stage of Labor
Begins with cervical dilation 10 cm and ends with delivery of the baby Primip: 1 – 2 hours Multip: > 1 hour Cervix: fully dilated and effaced Contractions: • Frequency: 1–2 min • Duration: 50–60 min • Intensity: less painful, expulsive • Heavy blood show ROM Station: Primip: +2 to +4; Multip: +2 to +4
Second Stage of Labor Characteristics
intra-abdominal pressure (bearing down)
urge to push
perineum bulges and flattens
perineal burning and stretching
Second Stage of Labor Interventions
Assessment:
o VS q1 hrs
o Assess position, station and progress by SVE
o Assess FHR after every contraction
o Assess pt’s readiness and urge to push
Encourage controlled breathing and rest between contractions
Reassurance
Support legs, chest, arms, and back
Position changes (off patient’s back): upright
Third Stage of Labor
Begins with the delivery of neonate and ends with delivery of placenta
Duration 1 – 20 minutes
Less painful
Characteristic: relieved
Third Stage of Labor Nursing Interventions
Maternal VS q15 minutes Assess for bleeding and complete placental detachment Encourage relaxation Fluid intake Assess condition of newborn at birth Apgar scoring 1 minute and 5 minutes Maintain fetal body heat (skin-to-skin) Baby I.D Reassurance, praise Explain after delivery procedures
Fourth Stage of Labor
First 2 – 4 hours after birth
Characteristics: post-partum chills, hunger, thirst, drowsy, moderate to heavy lochia, painless contraction
Fourth Stage of Labor Nursing Interventions
VS q15 minutes for the first hour then every 1 hour (for the next 2 – 4) then every 4 hours
Assessment of fundus and lochia q 15 min X 1 hour then q30 minutes
Repositioning for comfort
Diet and fluid as tolerated
Assessment of Fetus:
• VS q15 min X 1 hour then q30 min
• Keep on skin to skin contact for at a least one hour after birth
• Initiate breast feeding
• Give routine meds
• Maintain thermoregulation
• Initial head to toe assessment
Five “P”s of Labor
Power Passenger Passageway Position Pyschology
Power
- Primary – maternal pushing during the second stage of labor
- Secondary – contractions occur in the second stage of labor
- Blood supply to the cervix 800 – 1000mL/min
Passenger
Fetal descent through the birth canal is determined by: Size of fetal head Fetal lie Fetal attitude Fetal position Fetal presentation
Size of Fetal Head
If too big (macrosomia) then a vaginal birth will not happen
Molding of the fetal head will happen during a vaginal birth
Fetal lie
- Where the baby’s spine in reference to mother’s spine
* Want baby to be longitudinal with head toward pelvis
Fetal Attitude
Relationship of fetal parts to one another (rounded appearance)
• Head is in complete flexion in a vertex presentation
• Chin is touching chest
• Fetus back becomes convex
• Arms crossed over thorax
• Legs flexed at the knees
Fetal position
- Relation of the denominator or reference point to the maternal pelvis
- Want the occipital bones to be the presenting bones in the pelvis b/c they have the molding capability
- Occipital bones be facing anterior (front) for an easy transition of the fetus through the birth canal (OA)
ROA
right occiput anterior
occipital bones facing the right side of the mother’s pelvis and facing anteriorly
Any position that is not R/L OA:
Will delay or impede fetal descent o Causing mother to: Use more primary power Have severe back pain o Second stage of labor is prolonged o Changing positions sometimes helps Position mother on all fours Use of a peanut High Fowlers position
Fetal Presentation
• Cephalic presentation
o Vertex position (normal): fetus head first and facing backwards
Breech Presentation
Breech –> head entrapment complication –> fetal death
o Head entrapment happens when pressure is released from the uterus once majority of the baby is delivered causing the cervix to close before the fetal head has been delivered and closes around the neck
Frank breech
Complete breech
Footling breech
Shoulder Dystocia
Passageway
Station
Effacement
Station
Where the baby is at in the mother’s pelvis
Feel for cervix, diameter of cervix, and fetus head
Measured from -5 to +5
0 station: baby’s head is at the ischial spine
o Creating pressure on the cervix
+5 station: baby is completely delivered
Nursing Interventions for baby at -1 or -2 and dilation in the active stage:
o Ambulation!!!
o Birthing ball
Opens pelvis by increasing anterior-posterior diameter
o Peanut
Placed b/w legs for patients in bed to help open legs to further progress fetal descent
Closed Cervix
2 cm thick
4 cm length
Effacement
- Thinning of the cervix
- Measures: 0, 25, 50, 75, 100% (completely thinned out)
- Primip: usually thins out first then dilates
- Multip: occurs simultaneously
Pyschology
Influenced by: culture social support childbirth preparation expectations
Position
Maternal position during labor and birth
Positioning in 1st Stage of Labor:
- Upright: walking, sitting, kneeling, or squatting
- Lateral position: Decreases compression of the maternal descending aorta and ascending vena cava
- Upright position: Aiding the descent of the fetus and more effective contractions
Positions in the 2nd Stage of Labor
- Common is lithotomy position
* Upright position: Increase pelvic outlet and better fetal alignment with the pelvic inlet
Why do frequent position changes?
reduction of fatigue, and increase in comfort, improved circulation to the mother and fetus
Cardinal Movements of Labor
Process that is important for the fetus to move into the fetal descent
- engagement
- descent
- flexion
- internal rotation
- extension
- external rotation
- expulsion
Engagement
Fetal head passes through the pelvic inlet
Descent
Movement of the fetus through the birth canal during the 1st and 2nd stages of labor
Flexion
Fetus chin moves toward the chest, occurs when the descending head meets resistance from maternal tissues
Internal rotation
Rotation of the fetal head aligns the long axis of its head to the long axis of the maternal pelvis
2nd stage of labor
Extension
Resistance of the pelvic floor causes the presenting part to pivot beneath the pubic symphysis and the head to be delivered
2nd stage of labor
External rotation
Sagittal suture moves to transverse diameter and the shoulders align in the anteroposterior diameter
Maintains alignment with the fetal trunk as the trunk navigates through the pelvis
Expulsion
Shoulders and remainder of the body are delivered.
Pain Management During Labor
Can be managed Pharmacologically or Non-pharmacologically
Pain is caused by:
Uterine Muscle Hypoxia Lower Uterine and Cervical Stretching Pressure on the pelvis Traction on the pelvic structures Perineum pressure (baby is in 2nd stage) Influenced by Culture
Analgesics
opioids
narcotics
barbiturates
anti-histamines
Regional Anesthetics
Epidural Block
Intrathecal Space
Epidural Block
Administer at least dilation of 4 cm - Know Plt count before administration - Needs to be over 100,000 - Below 100,000 risk for bleeding Local anesthetic + opioid 500 – 1000 mL glucose fluid prior to administration Affects mothers BP or uterine blood flow leads to fetal distress - N/V, pruritus, respiratory depression
Pre-anesthesia Nursing Care
- Patient Hx: allergies
- Assess FHR
Call physician, CRNA, anesthesiologist
• Obtain consent form - Check SVE cervical dilation
- Check lab values (Plt count)
- IV fluid bolus with NS or LR
- Ensure emergency equipment is available
- Do a time-out procedure
- Bed is laid flat
- Patient is sitting straight on the edge of bed, hunched forward
• Hug a pillow and hunch their head
• Do not want the patient to be moving
Post-anesthesia Nursing Care:
- Lay the patient down on the bed on side to avoid compression of major vessels
- Monitor maternal VS and FHR q5 minutes initially and after every re-bolus then q15 minutes
• FHR alterations
• Hypotension (Systolic BP <90) - Assess pain and level of sensation and motor loss q1 hour
- Assess for any adverse reactions
• Pruritus, N/V, HA - Foley Catheter
Hypotension from epidural
• Alert CRNA or anesthesiologist (who ever did the epidural placement)
• Fluid bolus (500 – 1000 mL) to raise BP
• If any medications are given to raise mom’s BP normally causes decrease blood flow to the uterus
o Ephedrine
Does not compromise blood flow to the uterus
Nurses and CRNAs can administer
Demerol
Opioid
Rarely used b/c does not help in labor pain
Side effects N/V, CNS depression and Neonatal Respiratory Depression
Morphine
Opioid Less side effects (CNS depression and Neonatal Respiratory Depression) Given IM or IV (quicker) Administered during latent labor Only lasts a couple of hours
Butorphanol (Stadol) & Nalbuphine (Nubain)
Opioid agonist-antagonists
No respiratory depression in mother or neonate
Contraindicated for women with prior drug abuse
Sublimaze (Fentanyl)
Short-acting opioid antagonist
Crosses the placenta rapidly
Side effects: FHR alterations, Hypotension, CNS and respiratory depression
Non-Pharmacological Interventions
o Rhythmic breathing o Paced breathing o Labor Breathing Techniques o Hydrotherapy o Ambulation o Sitting on a birthing ball o Relaxation through: Massage Music (any type of music) Imagery Biofeedback Aroma therapy
Estimated blood loss in during a vaginal delivery
500 cc
Estimated blood loss in during a C-section
1000 cc
