Week 4 - Labour and Birth Process Flashcards
Labour
process of moving the fetus, placenta, and membranes out of the uterus and through the birth canal
T or F: There is one main factor that triggers labour.
FALSE
multiple factors
When do signs of labour appear?
weeks to days before labour
Signs of proceeding labour (many)
lightening or dropping
urinary frequency
backache (loosening joints)
stronger Braxton Hicks contractions
weight loss of 0.5 to 1.5kg (pee, fluids)
surge of energy - nesting
increased vaginal discharge or bloody show (mucous plug)
cervical ripening
possible rupture of membranes
Does dropping occur later in a nulliparous or multiparous client?
multiparous
just before onset of labour
nulliparous - few weeks before
Factors involve in the onset of labour
maternal AND fetal signals
changes in maternal uterus, cervix, and pituitary gland
stretching of the uterus leads to increased pressure on the cervix which sends signal to pituitary gland to secrete oxytocin to start contractions
Hormones involved in onset of labour (7)
1) estrogen - increase
2) oxytocin - increase
3) prostaglandins - increase
4) progesterone - decrease
5) endorphins
6) adrenaline
7) prolactin
Estrogen role
Oxytocin role
strong contractions for labour to progress
Prostaglandin role
softening of cervix
getting it ripened, ready
Progesterone role
required to maintain a pregnancy
as you get closer to labour, level will drop
Endorphins role
pain management
sense of well-being
Adrenaline role
alertness and energy
Prolactin role
maternal milk supply
maternal attachment
5-1-1 Rule
1) contracting every 5 minutes
2) contractions are at least 1 minute
3) pattern has been regular for 1 hour
Signs of Prelabour
irregular contractions
often stop with walking
felt in back or abdomen
no significant dilation or effacement
cervix often posterior
Signs of True Labour
regular, stronger, lasting longer and closer together
more intense with walking
felt in lower back, radiating to lower portion of abdomen - like a belt
changes to softening, effacement, dilation
anterior position
bloody show
Effacement
shortening and thinning of the cervix during the first stage of labour
expressed from 0 to 100 %
Presentation
part of the fetus that enters the pelvic inlet first and leads through the birth canal
Dilation
enlarging and widening of the cervical canal
1cm to full 10 cm
use fingers to determine dilation
inner cervix measurement
What marks the end of the first stage of labour
10 cm dilation
Dilation progression - cm
1 cm - can’t get finger in
3 cm- can get 2 fingers in tightly
4 cm - 2 loose fingers
5 cm - 2 loose fingers+
10 cm - completely open, won’t be able to feel any cervix
Engagement
largest transverse diameter of the presenting part (biparietal diameter) has passed through the pelvic inlet into the pelvic cavity
Crowning
head or the presenting part appears at the vaginal opening
Station
talk about descent in terms of stations
relationship of presenting part to imaginary lines drawn between maternal ischial spines & measures the degree of decent
1 cm above the spines = -1
At the level of the spine = 0
Birth imminent, presenting part = +4 to +5
“plus 4, on the floor”
4 cardinal Qs to assess progress of labour
1) vaginal discharge
2) vaginal bleeding
3) contractions
-frequency, how long, intensity, regularity, pain
4) fetal movement
Factors affecting labour - 5 Ps
Passenger - fetus and placenta
Passageway - birth canal
Powers - contractions
Position of mother
Psychological response
Passenger
size of fetal head
fetal presentation
fetal lie
fetal attitude (flexion)
fetal position
Lie
Longitudinal: cephalic or breech
Transverse: long axis of fetus (spine) directly across maternal spine
Attidude
flexion or extension
Presentation
part of the fetus that enters the pelvic inlet first
cephalic, breech, shoulder
Fetal position
relationship of a reference point on the presenting part to the four quadrants of the mother’s pelvis
Fetal position 3 letter abbreviation
1: R/L
presenting part in the right or left of the mother’s side of the pelvis
2: O/S/M/Sc
specific presenting part of the part of the fetus
3: A/P/T
location of the presenting part in relation to the maternal pelvis
O
occiput
S
sacrum
M
mentum/chin
Sc
scapula
Best position(s) for vaginal delivery
ROA
LOA
Frank Breech
presentation: Breech
presenting part: S
lie: Longitudinal
well flexed
best case scenario for Breech
if butt can pass, good chance shoulders and head will too
Single Footling
CANNOT deliver vaginally
need C-section
In the passageway, what measurement matters the most?
true brim
INNER aspect of the circumference is what matters
Types of powers (2)
1) Primary Powers - INVOLUNTARY
-effacement
-dilation
-Ferguson reflex: oxytocin is released, uterine contractions occur, + feedback loop
2) Secondary Powers - VOLUNTARY
-bearing down efforts
The client has better control over the bearing down efforts when ……
they’re unmedicated
Guiding client re bearing down efforts
push during contractions
3 good pushes/contraction
perineal muscles - pushing
Position
affects anatomic and physiologic adaptations to labor
frequent changes in position good
encourage to find positions most comfortable
upright, squatting
Position considerations with an epidural
supported - risk of falling
in bed, ball, pillow
Psychological
psychological state
supports
preparation
Why is sufficient relaxation between contractions important?
during contraction - decreased perfusion from placenta to fetus
want fetus to build up its oxygen reserves for the next contraction
Stage 1 of Labour
begins with the onset of regular contractions & lasts until full dilation and effacement of the cervix
early/latent phase & active phase
Stage 1 of Labour - Early/Latent Phase
0 – 3 cm dilation in a primiparous
cervical length less than 1cm or 75% effaced
typically lasts 6-8hrs
contractions mild to moderate and irregular
q5-30 mins for 30-45 secs
brownish discharge, mucous plug or pale pink
Stage 1 of Labour - Active Phase
beginning at 4cm in a nulliparous or 4-5cm in a multiparous
typically 3-6hrs
contractions are moderate to very strong, more
regular
q2-5mins lasting 40-90 secs
pink to bloody mucous
Stage 2
begins: full dilation (10cm) and complete effacement (100%)
ends: birth
active and passive phases
median duration: 50-60 mins nulliparous, 20-30 mins multiparous clients
epidural lengthens this stage
Stage 2 - Passive
dilated but resting, allow baby to further descend into pelvis
Stage 2 - Active
feel urge to push, patients with epidural may not feel this
epidural may change the length of this stage
promote upright position
Signs of Stage 2
urge to push or feeling need to have a BM
episode of vomiting
increased bloody show
shaking extremities
increased restlessness
verbalizing “I cannot do this” “I cannot go on”
Labour arrest in Stage 2
increases rates of operative births and complications
position changes: side-lying, squatting or sitting
Diagnosis of failure to progress
2nd stage
at least 3 hours in nulliparous
2 hours in multiparous
Nursing Care First Stage
family centred approach (use of genogram)
triage assessment to determine signs of labour
collection of admission data (antenatal records)
orientation to unit and healthcare team members & roles
Nursing Care Second Stage
vitals q5-30 mins
low risk: FHR q5mins
continuous electronic monitoring: high-risk
assess contraction pattern and bearing down efforts
Passive phase: help rest in comfortable position, conserve energy, promote progress of fetal descent by position changes
Active phase: Bearing down efforts, cleanse perineum if BM, coach to pant and breath
calm and quiet environment
administer oxytocin after the birth of the anterior shoulder
Stage 3
quick stage!
following the birth of the baby and the delivery of the placenta
Goal: prompt separation and expulsion of the placenta
most placentas - expelled within 15 minutes
longer than 30 minutes, considered retained placenta
active management, placenta separation and expulsion are facilitated by oxytocin
postpartum hemorrhage
Nursing Care Stage 3
skin to skin and delayed cord clamping (60 sec to 2 mins)
maternal vitals q15mins
assess bleeding and signs of placental separation
instruct the client to push when signs of placental separation
-sudden gush of dark blood
-lengthening of the cord
-shape of uterus becomes globular
Why is delayed cord clamping important?
more blood volume from placenta can get to the newborn
more RBCs, reduced mortality in preterm babies
anemia prevention
What do we administer for post-partum hemorrhage?
oxytocin
Stage 4
HIGHEST RISK OF HEMORRHAGE
1-2 hours after birth
after the delivery of the placenta in which the uterus effectively contracts
mother’s body functions begin to stabilize
Nursing Care Stage 4
vitals q15mins for the first hour
fundal assessment - want firm
fundal massage if fundus is boggy
encourage voiding and follow BMP (encourage peeing!)
observe lochia (small or no clots)
assess perineum - tears
Assess lacerations repair or episiotomy for REEDA
-Redness
-Edema
-Ecchymosis
-Drainage
-Approximation
encourage breastfeeding in the first “golden hour”
Communication Guidelines during Labour and Birth (many)
welcome in a personal manner
explain role
calm and confident***
know before entering
ask about feelings and concerns
discuss birth plan
assess need for knowledge re pain management
ask permission
focus on client
let them know when you’ll return
engage them in convos with other HCPs
GBS is screened for between ___ and ___ weeks
35 to 37 weeks
GBS
considered normal vaginal flora in a client who is not pregnant
present in 10-30% of healthy pregnant individuals
concern about vertical transition from the birth canal of the infected mother to the infant during birth
risk factors: preterm birth, PROM > 18 hours, intrapartum maternal fever, and positive history of early onset neonatal GBS
What would you give to a client that is GBS positive?
IV antibiotics prophylaxis
most often Penicillin G
What can GBS cause
pneumonia, meningitis
fever
UTIs
When are antibiotics automatically given?
previous history of GBS
HSV
careful examination and questions re: symptoms at the onset of labour
if visible lesions are not present when labour begins, vaginal birth is acceptable
infants born though an infected vaginal are at risk of neonatal herpes simplex virus
active lesions = C-section
Meds for HSV
acyclovir
valacyclovir
Rupture of membranes
patients may report sudden gush or slow leak
not always a lot of fluid or super evident
assess for this
Assessing for rupture of membranes
COAT
sterile speculum examination
Nitrazine or fern test to confirm
COAT
C - colour
-amniotic fluid should be clear
-bleeding = rupture, meconium
O - odour
-no foul odour
A - amount
-a little or a lot
T- time
-when they ruptured - increased risk with prolonged rupture
Fern test
GOLD STANDARD
crystalization in the amniotic fluid
speculum exam - look for fluid in the vagina
bear down and cough
put on a slide
Nitrozene swab
looks at pH
intact membranes = yellow
ruptured membranes = blue (amniotic fluid more neutral)
false positive - vaginal bleeding, has had intercourse and there is semen
quick, cost-effective, but not a confirmation
Physical Assessment on Admission (many)
vitals
Leopold’s maneuver
-fetal position and lie
FHR and pattern
-oxygenation
uterine activity
-regular, strong, increasing in duration
vaginal examination
-internal os
urinalysis
-protein in urine - preeclampsia
blood work
-on admission - CBC, coag, blood type, R factor
Maternal Physiological Adaptation during Labour (many)
CO increases
HR and RR increases slightly
BP increase during contractions and return to baseline between contractions
WBC increases
slight increase in temp (investigate over 38)
proteinuria up to 1+ may occur (bad: +3, +4)
gastric motility is decreased
N&V in active phase
blood glucose levels decrease (drink Gato, fluids)
endorphins for pain
When should you assess BP?
BETWEEN contractions
Fetal Physiological Adaptations to Labour
FHR
fetal circulation
fetal respirations (changes to prepare for initiating respirations after birth)
-fetal oxygen pressure decreases
-arterial carbon dioxide pressure increases
-arterial pH decreases (acidosis)
-bicarbonate levels decrease
-fetal respiration movements decrease during labour
-lung fluid is cleared from the air passage as the infant passes through the birth canal
There is more risk for breathing issues with a
a) vaginal birth
b) C-section
b) C-section
don’t have acidosis or mechanical compression to squeeze out the fluid
Hypertension disorders in pregnancy
1) Pre-existing (chronic) hypertension
2) Gestational hypertension
3) Preeclampsia
Pre-existing (chronic) hypertension
before the pregnancy or diagnosed before 20 weeks of gestation
Gestational HTN
appears for the first time at or beyond 20 weeks gestation
Preeclampsia
BP of equal or greater than 140/90 x two readings 15 mins apart
new onset of proteinuria: concentration of 0.03g/L or more in at least 2 random urine specimens collected at least 6 hours apart
should be based on the urinary protein: creatinine ratio or 24- hour urine collection
1+ adverse condition (see later slide)
1+ or more severe complications
clinical continuum from mild to severe
Preeclampsia S&S
headache that won’t go away
SOB
blurry vision
pain in abdomen or shoulder
swelling of face or hands
N/V
sudden weight gain
140/90
Severe Complications with Preeclampsia
oliguria
altered LOC, confusion, headache
eclampsia or stroke
scotoma or blurred vision
hepatic damage or rupture
RUQ pain
impaired liver function, elevated liver enzymes
thrombocytopenia with platelets less than 50x109/L
anemia
pulmonary edema
fetal growth restrictions
Eclampsia
RARE
serious
seizures from the profound cerebral effects of pre-eclampsia
usually preceded by:
-headache, severe epigastric pain and hyper-reflexia
-normal reflex: +2
placenta, liver, kidneys, and brain is depressed by as much as 40-60%
Risks with Eclampsia
Fetal Risk
-Placenta abruption
-Preterm birth
-IUGR
-Acute hypoxia
HELLP Syndrome
life threatening pregnancy complication
symptoms of severe pre-eclampsia plus hepatic dysfunction
impaired liver function
epigastric (RUQ) pain
HELLP acronym
H =Hemolysis
EL = Elevated liver enzymes
LP = Low platelets
HELLP syndrome risks
placental abruption (placenta separating from the uterus)
renal failure
pulmonary edema
ruptured liver hematoma
disseminated intravascular coagulation (DIC)
fetal and maternal death
small-for-gestational-age infants
Nursing Care Management for Severe Preeclampsia and
HELLP Syndrome
hospital care (close monitoring of maternal and fetal well-being)
Medications to control BP
-Labetalol
-Nifedipine (Adalat)
-Hydralazine (Apresoline)
-Aldomet (a-methyl-dopa) - chronic HTN
low dose Aspirin
monitor for seizure activity –> Magnesium sulfate
lateral position to facilitate blood flow to placenta
monitor pain
delivery of the infant may be warranted
Prevention of seizures
mag sulf
4 gm IV bolus followed by 1-2 gm/hr IV
monitor for toxicity and boggy uterus
Antidote for magnesium sulfate toxicity
10% Calcium Gluconate
GDM
elevated glucose levels that are first recognized during pregnancy
universal screening
target blood glucose levels 3.7 - 6.7 mmol/L
Screening for GDM
GCT - 50 g
Diagnosis GDM
GTT - 100 g
