Unit 3 Flashcards
What are the passengers in labor?
Fetus and Placenta
Describe the fetus as a passenger
Head, shoulders, molding
Size of fetal head: the biggest thing to go through the birth canal is the baby’s head; the head can mold and fit through the birth canal .
Molding: because the bones are not firmly united, slight overlapping or molding of the shape of the head occurs during labor.
Size of fetal shoulders: the next biggest thing to come out of the birth canal. When the baby is coming out, the anterior shoulder needs to come out first, then the posterior shoulder.
Describe the fetus’ fontanel
2 fontanels: membrane filled spaces where the sutures intersect.
Where they are located: ADPT
Anterior is a Diamond; Posterior is a Triangle
After Rupture Of Membranes: sutures and fontanels can be palpated to determine fetal position
Describe presentation and presenting part in labor
Fetal presentation
What part of the fetus do you want to come out first?
Presentation: part of the fetus that enters the pelvis first and leads through the birth canal during labor
- Cephalic (head)
- Breech (butt or feet or both)
- Shoulder
Presenting part: part of the fetus that lies closest to the cervix
- Fetal presentation: determined by the fetal presenting part
- Different parts of the head can come out first:
- Mentum = chin
- Sinciput = front of head
- Occiput = back of head
You want the occiput to come out first = vertex
Describe what lie means during labor
Lie: relation of the spine of the fetus to the spine of the mother
Longitudinal or vertical - the baby’s spine is going longways in line with the mother’s spine
Transverse or horizontal - the mother and baby’s spine makes a “T” the baby cannot come out transverse, have to have a C section
Sometimes preterm babies are able to move easily from this position, but term babies have harder time
Describe what attitude means during labor
What should the fetal attitude be?
Attitude: relation of the fetal body parts to each other
Fetal attitude
General flexion: the baby’s chin is against the chest, the arms are bent at the elbow and crossed over the abdomen, the knees are flexed, and the hips are flexed, thighs are flexed on the abdomen
Describe what position means during labor and the abbreviation used
What position do we want the baby to be in?
What position makes it difficult?
Relationship of the presenting part to mother’s pelvis
3 part abbreviation
1st letter: location of the presenting part (R) or (L)
2nd letter: presenting part (O:occiput, S:sacrum)
3rd letter: location of the presenting part in relation to the anterior (A), posterior (P) or transverse (T) portion of the maternal pelvis
We want the baby to be “OA”
OP - “sunny side up” the baby’s face is looking up, it is hard for the baby to come out
Describe the different breech presentations in labor
Complete:
Frank:
Shoulder:
Footling:
Complete breech: the baby is in general flexion, but it is flipped “butt first”
- Lie: Longitudinal/vertical
- Presentation: Breech (sacrum and foot presenting)
- Presenting part: Sacrum (with feet)
- Attitude: General Flexion
Frank breech: the baby is in general flexion and flipped, but the legs are straight
- Lie: Longitudinal/vertical
- Presentation: Breech (incomplete)
- Presenting part: Sacrum
- Attitude: Flexion, except for legs at knees
Shoulder presentation: coming out shoulder first
- Lie: Transverse or horizontal
- Presentation: Shoulder
- Presenting part: Scapula
- Attitude: Flexion
Single footling or double footling: one or both feet are coming out first
- Lie: Longitudinal/vertical
- Presentation: Breech (incomplete)
- Presenting part: Sacrum
- Attitude: Flexion except for one leg extended at hip and knee
Describe what station and engagement means during labor
Station: referring to how far high or low is the baby’s head in relation to the ischial spines, a measure of the degree of descent of the presenting part of the fetus through the birth canal.
Represented in cm.
Engagement: If baby’s head is in line with the ischial spines: “station 0”.
When the lowermost portion of the presenting part is 1 cm above the spines, it is noted as being − 1.
When the presenting part is 1 cm below the spines, the station is said to be + 1.
Birth is imminent when the presenting part is at +4 to +5 cm. (+5 = crowning)
Describe the passageway in labor
What must happen for the baby to come out?
Composed of: Bony pelvis; Soft tissues: Lower uterine segment, Cervix (thins out and dilates), Pelvic floor muscles (pelvic floor is below the pelvis), Vagina (dilates when mom starts pushing), Introitus
In order for the baby to come out, the uterus contracts, causing the cervix to open up and thin out; the uterus starts squeezing out the baby; the pelvic floors soften and relaxes as the baby starts to come out; the vagina has to dilate as well as the baby starts to come, this DOESN’T HAPPEN UNITL MOM STARTS PUSHING ; this is a slow pushing, which we prefer because the vagina is more likely to tear as the baby comes out.
(BOOK) After labor has begun, uterine contractions cause the uterine body to have a thick/muscular upper segment and a thin-walled lower segment. A physiologic retraction ring separates the two segments. The lower uterine segment gradually distends to accommodate the intrauterine contents as the wall of the upper segment thickens and its accommodating capacity is reduced. The contractions of the uterine body thus exert downward pressure on the fetus, The cervix effaces (thins) and dilates (opens) sufficiently to allow the first fetal portion to descend into the vagina
Describe how the fetus adapts to labor
Circulation, Respiration
Fetal heart rate (110-160 bpm): Monitoring gives us reliable and predictable information about the condition of the fetus related to oxygenation
Fetal circulation
- Affected by maternal position, uterine contractions, blood pressure, and umbilical cord blood flow
- If mom is laying a certain way, this could affect fetal circulation; we do NOT want mom flat on her back, this cuts off blood flow in the vena cava, cutting off blood flow to the uterus and placenta
- Every time the uterus contracts, the blood flow is cut off a little bit
- BP: if blood pressure drops, the blood is not circulating well in mom, so it is not circulating well to the baby
- High BP also affects circulation to baby
Fetal Respiration
- Changes stimulate chemoreceptors in aorta and carotid bodies to prepare fetus for initiating respirations after birth
Why do we monitor fetal response during labor?
What is the goal for fetal monitoring during labor?
Fetal oxygen supply can decrease due to…
- Reduction of blood flow: Result of maternal BP (hypo or hypertension) or bleeding (hypovolemia)
- Reduction of oxygen content in maternal blood: Result of bleeding (or anemia)
- Alterations in fetal circulation: Result of cord compression, partial placental separation or complete abruption, or head compression
- Reduction of blood flow to intervillous space in placenta: Result of uterine hypertonus or deterioration of placental vasculature (d/t hypertension or diabetes)
Goal:
- Identify and differentiate normal patterns from abnormal patterns
- Fetal hypoxemia: baby does not have enough oxygen in the blood
- Fetal hypoxia: not enough oxygen at the cellular level, leads to metabolic acidosis
Describe intermittent auscultation as a monitoring technique during labor
Advantages and Disadvantages?
Fetal Heart Tones
- Listening to fetal heart sounds at periodic intervals to assess FHR
- Doppler, ultrasound stethoscope, fetoscope or external fetal monitor
- Advantages: easy to use, inexpensive, and less invasive than EFM, more comfortable for the woman and gives her more freedom of movement
- Disadvantages: may be difficult to perform transabdominally in women who are obese, significant events may occur during a time when the FHR is not being auscultated, IA does not provide a permanent documented visual record of the FHR and cannot be used to assess visual patterns of the FHR variability or periodic changes
Contractions: keep the fingertips over the fundus before, during, and after contractions; we want the uterus to be soft or relaxed before and after. Intensity: mild. moderate, strong. Duration: seconds, beginning to end of contraction. Frequency: minutes, beginning of one contraction to the next. Resting: soft (good) or hard (not good)
Describe Electronic Fetal Monitoring
External
External Transducers
Ultrasound transducer - High-frequency sound waves reflect mechanical action of the fetal heart. Placed over the area where fetal heart rate is best heard (usually below umbilicus)
Tocotransducer - placed on the fundus; picks up the pressure exerted on the monitor; can only tell you the frequency and duration of the contractions, not the strength of the contractions
Describe Electronic Fetal Monitoring
Internal Mode
- Spiral electrode (FSE): converts the fetal electrocardiogram as obtained from the presenting part to the fetal heart rate via a cardiotachometer; placed on fetal head
- Intrauterine pressure catheter (IUPC): can tell you frequency, duration, and strength of contractions; placed into uterine cavity
Before putting on internal monitors, the water has to be broken (membranes have to be ruptured)
Describe maternal adaptations to labor
Cardiovascular changes
Cardiac output: increases 10-15% during the 1st stage; 30-50% during the 2nd stage
Increase in HR and BP: still shouldn’t be outside of the normal range
- Labor is painful and can cause anxiety -> can lead to increase in HR and BP
- Know what the pt’s baseline is
Supine hypotension: lying flat on back leads to low BP
- Make sure mom is never flat on her back
- Better to lay mom on her side, on laying up in bed
Describe maternal adaptations to labor
Respiratory changes
Renal changes
Integumentary changes
Musculoskeletal changes
Gastrointestinal changes
Respiratory changes
- Increased respiratory rate related to increased physical activity and need for oxygen
Renal changes
- Voiding: may be difficult for various reasons such as tissue edema caused by pressure from the presenting part, discomfort, analgesia, and embarrassment
Integumentary changes
- Stretching of the introitus: pelvic floor, vagina, and introitus are stretching for the baby to come out
Musculoskeletal changes
- Backaches related to pelvic relaxation; the pelvis can soften and widen
Gastrointestinal changes
- Stomach emptying time is delayed
- Nausea and vomiting are common - can be experienced related to the pain in labor, or it could be just part of the labor process
Signs Preceding Labor
- Lightening: The baby and uterus is “dropping”, happens around 2 weeks before term; usually leads to more urgency to void. In a multiparous woman, lightening may not take place until after uterine contractions are established and true labor is in progress
- Low back ache & sacroiliac distress (result of relaxation of pelvic joints)
- Braxton hicks contractions: Irregular contractions before you are in labor
- Loss of mucous plug/ bloody show (brownish, blood tinged mucus)
- Possible rupture of membranes: “water breaking” does not always indicate labor, but mom should go to hospital because risk of infection is increased
- Surge of energy
- Weight loss of 0.5-1.5 kg (1-3.5lbs): can be due to water loss
- GI disturbances: diarrhea, nausea, vomiting
Distinguish false labor from true labor
False Labor
- Contractions: Irregular or regular but very temporary; go away with simple measures: getting up and walking around, drinking water, going to the bathroom, taking Tylenol, warm shower or bath
- Contractions felt above umbilicus or in lower back
- Cervix: cervical exam done in office at 35-37 week mark
True Labor
- Contractions: occur regularly, becoming stronger, lasting longer, and occurring closer together
- Walking around makes contractions worse
- Contractions felt in the lower back, radiating to the lower portion of the abdomen
- Cervix: only thing that indicates true labor is regular contractions leading to dilating cervix; “softening” of the cervix; starts to dilate or open; thins out; becomes more anterior (usually posterior); bloody show occurs when the cervix is opening and thinning (the cervix has a lot of capillaries), brownish-to-bloody discharge
- Fetus: the fetus is coming down and becoming engaged (in nullips, engagement happens before labor, while in multips it occurs during labor)
- Multifactorial: increase in estrogen, decrease in progesterone
First stage of labor
How does it begin and end?
What are the phases? (contractions, how the mom feels, multips vs. nullips)
Duration?
The 1st stage begins with regular uterine contractions and ends with full cervical effacement and dilation
- Dilation: 1-10 cm
- Effacement (thinning): 0-100%
- Station: -5 to +5
Latent phase (0 to 5 cm dilation):
- Mom is relaxed and calmer, able to walk around when there is not a contraction
- Contractions about 2-30 min apart, lasting 40-60 seconds
- A little bloody show (brownish, mucus(
- Nullips and Multips go through this at about similar rates
Active Phase (6-10 cm dilation):
- Contractions are “booming out”, hopefully every 2 min, lasting 60-80 seconds
- Mom is in pain, she should still have relief in between contractions
- More bloody show (pink to bloody)
- Mom is more quiet, agitated
- Mom may experience more backache
- Nausea, vomiting
- Mom may feel like she is losing self-control
- Nullips usually are not as fast in this stage; average 1 hour per cm
- Multips vary; usually more rapid
Duration
- Less than 1 hour and up to 20 hours
What to include in interview during first stage of labor?
What to do at hospital?
Multip vs. Nullip
Why did she come to the hospital?
Contractions?
Frequency: how far apart are contractions?
Duration: how long are contractions?
Interventions?: have you done anything to make the contractions go away?
How painful are the contractions?
At hospital: urine sample, put on monitors, palpation
Get baseline maternal vital signs when she is NOT having a contraction
MATERNAL & FETAL VITAL SIGNS
Multip: come to hospital sooner
Nullip: may not come as soon
First Stage of Labor
What to do when woman comes to hospital for…
Rupture of membranes?
Bloody show?
Sent from MD office?
Rupture of membranes:
COAT
- Color: What is the color of the fluid that came out? It should be clear or white. We do not want yellow or green (meconium) or bloody fluid. Cloudy could mean infection.
- Odor: Is it foul or malodorous? Malodorous = infection
- Amount : How much came out? A trickle or gush?
- Time: What time did it break?
Nitrazine tests
- Dark yellow to orange means intact membrane.
- Green to blue means ruptured membrane.
- False positive: could be a result of KY Jelly or semen
Bloody show
- Make sure it is truly bloody show - a mucousy sticky pinkish red - and NOT actual blood
Sent from the MD office?
- At hospital: urine sample, put on monitors, palpation
- Urine sample is not always given if the water has broken due to amniotic fluid mixing in the urine
Admission Data and Prenatal Data
First stage of Labor
- Last food and fluid intake: for anesthesia purposes, esp if woman is having a c-section
Prenatal Data - Current pregnancy - GTPAL? Any complications with this pregnancy? What is the due date?
- Past medical and surgical history: Ever had surgery or anesthesia before?
- Previous pregnancies: Any problems with previous pregnancies? How were they treated? At what point in pregnancy did she deliver? How did she deliver?
- Type and screen, CBC, rubella, HIV, RPR, Hep B, etc
- Platelet count is important to know for anesthesia purposes
What to consider in a woman in first stage of labor
Birth Plan
Psychosocial factors
Stress in Labor
Cultural Factors
Birth Plan: Pain management, Breast or bottle feeding, Support available, Cultural/religious practices, Pediatrician, Environmental modifications, clothing worn, preferred labor activities, relaxation measures, care of and handling of newborn after birth,
Psychological Factors: Verbal interactions, Body language, Perceptual ability (able to comprehend), Discomfort level. History of abuse? Sexual abuse? Talk pt through entire process
Stress in Labor: Higher stress could mean more pain. Stress could be related to culture, expectations/fears of labor, who is in the room. Is partner/support person prepared for their role in labor?
Cultural Factors: Educate pt on options; Be culturally sensitive and respectful of cultural and religious practices; Interpreters for non-English speaking pt
What to include in Physical Exam during First Stage of Labor
What affects the speed of dilation?
Fetal Heart Rate - put mom on monitors first
Contractions
- Primary Powers
Vaginal examination (what tells us if she is in true labor)
- Dilation, Effacement, Station: 3/100/-2
- What affects cervical dilation?
- Movement: the more a woman moves, the faster dilation occurs
- Multips dilate faster than nullips
- Stress: slows down dilation
- The weight of the baby and amniotic fluid can affect dilation
- Force of the presenting part
- Scarring of the cervix (biopsy of cervix, or part of cervix remove) slows down dilation
- Multips tend to dilate and efface together
- In nullips, effacement usually happens faster than dilation
Labs to take during first stage of labor?
Analysis of urine specimen
Blood tests: CBC, H&H, type and screen
IV access: 18 gauge needed (for blood), green.
20 gauge = pink
Nursing Care during First Stage of Labor
General hygiene
- Use pads or towels and change them on a regular basis; this also prevents infection
Nutrient and fluid intake
- Oral intake: usually NPO, limited to ice chips only
- Intravenous intake (b/c they are NPO)
Elimination
- Voiding: want the bladder to be empty on a regular basis
- Usually when the water has broken, the woman can not get up to go to the bathroom because the cord could come out. Use bedpan or catheter.
- Catheterization - usually placed if mom has anesthesia (depending on hospital and HCP, you use foley cath or straight cath every 2-4 hours)
- Bowel elimination: normal to happen during labor
Ambulation
- Positioning: Semirecumbent, Lateral, Upright, Hands-and-knees (really good for moms experiencing back labor (baby is OP)), Peanut Ball (can help open up hips)
Support:
- Partner, Doula, Others
Describe pain experienced during the first stage of labor
Visceral Pain
Pain that is caused by…
Uterine ischemia; usually occurs in the lower portion of the abdomen
Distention of the lower uterine segment;
Stretching of the cervical tissue and the pressure on the pelvic floor muscles and pressure exerted on the nerves
The woman is free from pain when contraction is done
Describe factors influencing pain response
Perception of pain
Expression of pain
Influencing factors
Management
- Perception of pain: affected by stress, multip or nulip, culture, age, previous personal experience with pain, support available, preparation, the desire or no desire to have a natural birth
- Expression of pain: BP and HR increase, RR increase or may have hyperventilation, diaphoresis, N/V, crying
- Influencing factors: Affected by how tired mom is, how long she has been in labor, how big the baby is, how fast the whole process is occurring, anxiety, culture, previous experience
- Management
Describe ways to comfort a woman during labor
- Support
The more support a woman has, the better the experience an the less pain they have during labor
• Provide companionship and reassurance.
• Offer positive reinforcement and praise for her efforts.
• Encourage participation in distracting activities and nonpharmacologic measures for comfort.
• Give nourishment (if allowed by obstetric health care provider).
• Assist with personal hygiene.
• Offer information and advice.
• Involve the woman in decision making regarding her care.
• Interpret the woman’s wishes to other health care providers and to her support group.
• Create a relaxing environment.
• Use a calm and confident approach.
• Support and encourage the woman’s support people by role-modeling labor support measures and providing time for breaks.
Describe ways to comfort a woman during labor
- Environment
- Individuals present: how they communicate; their philosophy of care, including a belief in the value of nonpharmacologic pain relief measures and in the woman’s specific birth plan; practice policies; and quality of support
- Physical space: Should be safe and private, allowing the woman to feel free to be herself as she tries out different comfort measures. Stimuli such as light, noise, and temperature should be adjusted according to her preferences. The environment should have space for movement and equipment. The familiarity of the environment can be enhanced by bringing items from home
Describe Nonpharmacologic Strategies for Pain Management During Labor
Breathing Techniques
- When starting a contraction, it is helpful for the woman to take a “cleansing breath” in through the nose, out through the mouth; She can do this at the beginning and end of the contraction
- Slow-Paced Breathing: IN-2-3-4/OUT-2-3-4/IN-2-3-4/OUT-2-3-4…
- Modified-Paced Breathing: IN-OUT/IN-OUT/IN-OUT/IN-OUT… (avoid hyperventilation)
- Patterned-Paced or Pant-Blow Breathing: 3:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) or 4:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction)
Describe Nonpharmacologic Strategies for Pain Management During Labor
Effleurage
Counterpressure
Heat/cold
Effleurage - light stroking of the abdomen used in conjunction with breathing during contractions
Counterpressure - steady pressure applied by a support person to the sacral area with a firm object (e.g., tennis ball) or the fist or heel of the hand.
Heat: Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor.
Cold: Cold cloths, frozen gel packs, or ice packs applied to the back, the chest, and/or the face
**Don’t use heat or cold for too long, 15-20 min maximum
Sedatives in Labor
What do they do?
Most commonly used:
Promotes sleep, relieves anxiety
Could also lead to a longer latent phase
Most common used sedative: Phenergan (can also help with N/V)
Systemic analgesia during labor
When to use:
Side effects:
Examples
Only want to use these once labor is well-established (usually 4 cm)
Remember these readily cross the placenta and can lead to decreased RR, decreased LOC in both mom and baby.
We do not want this to happen to baby, there is a cut-off point where we don’t give this medication.
We want to give these meds IV NOT IM; to lower the amount the baby gets, give the medication during a contraction.
Opioid agonists: Demerol, fentanyl are commonly used
- Demerol can cause N/V
- Fentanyl works faster but doesn’t last as long
Opioid agonist - antagonists:
- Usually provide pain relief
- Don’t cause as much respiratory depression and N/V
- Can make you real tired
- Nubain, Stadol
Describe Spinal Anesthesia
(what’s it used for, how long it takes to work, how long it lasts, what part of the body is affects, etc)
- Typically used for C-section
- Feel relief within 5-10 min
- Works on T6 or nipple line down to the feet
- Only last 1-3 hours
- Only One dose (a shot)
- Mom is Completely numb
- Need a foley cath
Describe an Epidural
(what’s it used for, how long it takes to work, how long it lasts, what part of the body is affects, etc)
- Works on T10 down to the feet (if used for a c-section, it starts at T8)
- Given continuously through catheter
- You are still able to move and the pressure is not able to go away (baby’s head). “Feeling like you are about to have a bowel movement” = baby about to come out
- Foley or straight cath
Minor Side effects for spinal and epidural
Low BP
Itching
Limited movement
Prolong the second stage of labor (pushing of the baby)
Major Side Effects of Spinal/Epidural anesthesia and nursing interventions
Maternal hypotension with decreased placental perfusion
Interventions:
- Turn left lateral - left tilt (lay mom back 15-45 degrees and place a pillow or wedge under one hip)
- IV fluid bolus
- O2 by nonrebreather at 10-12L/min
- Elevate legs
- Notify MDA, CRNA, OB
- Medications (don’t need to know)
- Monitor maternal VS and FHR
Decreased BP, fetal bradycardia, absent/minimal variability
Impaired placental perfusion
Ineffective breathing pattern - issue with where the spinal or epidural got placed, if it goes too far up, it can affect mom’s respiratory system
Advantages and Disadvantages of Spinal Anesthesia
(interventions for disadvantages)
Advantages
- Ease of administration
- Absence of fetal hypoxia
- Mother is awake
- Muscular relaxation
- Non-excessive blood loss
Disadvantages
- Medication reaction
- Hypotension
- Ineffective breathing pattern
- After birth:
Bladder/uterine atony
Postdural puncture headaches (Spinal HA): caused by leakage of CSF from the site of puncture of the dura mater (membranous covering of the spinal cord)
- Prevention/Tx of Spinal HA: hydration, bedrest, medications can be given
- Tx of severe spinal HA: Epidural blood patch (taking the mom’s blood out and injecting it into the leakage to clot it)
