Unit 1 Labor and Delivery

What are the factors affecting labor? (the five P’s)

• Passenger (fetus & placenta)

• Passageway (the birth canal)

• Powers (physiological forces of labor)

• Position (relation between fetus and passage)

• Psychological considerations

Premonitory signs of labor?

• Cervical changes

• lightening- baby starts to lower

• mucus plug dispelled

• pressure lower, breathing easier

• back pain

• lower extremity edema

• frequent urination

• increased vaginal discharge

• nesting (burst of energy)

Attitude

Relationship of the fetus’ body part to one another.

• think “fetal position” (curled into ball)

Lie

How the spine of the fetus corresponds with the spine of the mother.

• horizontal, vertical, or oblique

Presentation

Part the is encountered first when doign a vaginal exam.

• cephalic, breech,…

Postion

How the part of the fetus corresponds to mother’s pelvis.

• left or right

• presenting part

• presenting part position

  • ex: left occipital anterior (best)

Engagement

Fetal presenting part is settling in mother’s pelvis

Station

Fetal presenting part as it relates to ischial spines.

What are Leopold’s Maneuvers?

Performed after 36 weeks by the healthcare provider to determine the baby’s position and estimate birth weght.

• checks to see if baby position is safe for vaginal birth

  1. feeling for buttocks and head

  2. feel for back

  3. determines presentation, palpate just above the symphysis pubis

  4. determine attitude, apply downward pressure in direction of symphysis pubis

What is the true pelvis and the best pelvic shape for birthing?

True pelvis: inner space the fetus must progress through.

Gynecoid is the best pelvic shape.

Cardinal Movements

• Engagement

• Descent

• Flexion

• Internal Rotation: rotates head 45° under pelvis

• Extension

• External Rotation: rotates back from the 45°

• Explusion

“Every Day Fine Infants Enter Eager & Excited”

Contractions

No control over, helps dilate cervix, can start spontaneously or be induced.

• Meant to move baby down and out

Does mom have control over pushing?

Yes.

• Let mom follow her own birth plan!

What can be done to induce labor?

This is done because of medical or elective reasons.

• elective must be at least 39 weeks

Methods:

• amniotomy (hook is used to pop sac)

• Oxytocin

• prostaglandin (helps ripen cervix)

What is the best position to give birth?

Upright.

• Laying on the back suppresses the vena cava & decreases venous return. Less blood to heart = drop in BP.

Throne position means heads up.

Nursing care of the labor patient?

• determine if patient is in labor

  • contractions alone are not labor

• determine if amniotic sac is intact

  • patient hx

  • nitrazine paper will turn blue in the presence of amniotic fluid

  • check color

  • yellow or green fluid may mean meconium

  • if ruptures at hospital, check to make sure baby is okay

True Labor

• Regular interval for contractions

• Increase in intensity and frequency

• Unrelieved with rest or hydration

• Pain starts in back, radiates to front

• Contractions continue no matter the activity performed.

False Labor

Braxton Hicks contractions.

• irregular intervals for contractions

• no change in duration and frequency

• contractions relieved with rest, hydration, or warm bath/

• felt high up and does not radiate

Reasons to go to birthing unit?

• Nulliparas: contractions 5 min apart x 1hr

• Multiparas: contractions 6-8 min apart x 1 hr

• Rupture of membranes

• Any vaginal bleeding

• Decreased fetal movement

Length of Contraction

Measured from the beginning of 1 contraction to the end or completion of the same contraction.

Measurement of Strength of contraction

Either by palpation or internal monitoring

Frequency of Contractions

From beginning of one contraction to beginning of the next contraction.

Acme

The highest point or peak of the contraction

Decrement

The portion of a uterine contraction after it reaches its peak (acme) and before it returns to baseline.

Duration

When you first feel the contraction until it is over.

Increment

The beginning portion of a uterine contraction between baseline and acme. Increasing strength of contraction is shown by the upslope record recorded by the fetal monitor

First Stage of Labor

Longest stage, 0-10cm dilation.

Onset of contractions to complete cervical dilation: includes 2 phases

• Latent

• Active

• Still ambulating

Latent Phase of First Stage

Gradual cervical change

• 0-6cm dilated, 0-40% effaced

• multipara average <5hrs

• primipara average 8hrs

• contractions vary every 20-30 mins

• contraction duration 30-45 seconds

• Contraction intensity mild

Active Phase of First Stage

More rapid cervical change.

• 6-10cm dilated, 40-100% effaced

• Multipara: 2-4hrs

  • cervix effaces and dilates at same time

• Primipara: 5-7hrs

  • cervix must first efface and then dilate

• Contractions every 1.5-5 min

• Contraction duration 40-60 seconds

• Contraction intensity moderate

Second Stage of Labor

Complete cervical dilation to birth.

• Variable; pushing stage

• Can last a few mins to a few hrs.

  • >3hrs increased risk of complications

• Fetal descent into pelvis

• Pt will feel the urge to push

• Contraction frequency 2-3min

• Duration 60-90 seconds

• Strong contractions

Third Stage of Labor

Birth to delivery of placenta.

• Placenta is guided out as expelled; watch for hemorrhage

• Lasts about 5-30 min

• Placental separation (detaching from uterine wall)

• Placental expulsion (coming outside the vaginal opening)

• Hallmark signs:

  • surge of blood from vagina

  • umbilical lengthening

  • fundus in globular shape

• skin-to-skin with mom

Fourth Stage of Labor

Initial Recovery

• Monitor VS as scheduled & laceration degrees

• Will have slight decrease in BP, slight increase of HR, uterus will be midline & firm = normal

• Maternal and fetal bonding

Cardiovascular Response to Labor and Delivery?

Cardiac output increases 31%, fluid distribution changes during a contraction, pain, pushing, anxiety, position (Vena Cava Syndrome)

Systemic Response to Labor and Delivery?

Blood pressure increases due to increase in cardiac output. Blood pressure can decrease due to supine hypotensive crisis, hypovolemia, hemorrhage, dehydration, metabolic acidosis, narcotics, and EPIDURALS.

• Increased WBC

• Increased body temp

• Decreased blood glucose

Fluid and Electrolytes response to labor and delivery?

Diaphoresis (sweating), hyperventilation, increased body temp, increased respirations, IV fluids.

Respiratory System response to Labor and Delivery?

O2 demand and consumption, metabolic acidosis uncompensated by respiratory alkalosis (by time of delivery).

Metabolic acidosis quickly reverses to normal in the fourth stage because of change in/increased respiratory rate.

Renal system response to labor and delivery?

Pressure can impair blood and lymph drainage; edema of tissues; renal activity increases.

What does it mean when baby is in 0 station?

Baby is engaged in pelvis.

What does it mean when the cervix is 100% effaced?

Should feel cervix, or it will be papery thin.

What are some non-pharmacological pain control methods for labor?

• environmental controls

• counter pressure for back pain

• endorphins

• hydrotherapy

• hypnotherapy

• coaching, doula

• breathing patterns

• Birthing balls

Goal: maintain pain relief without harming baby.

Pharmacological pain control methods?

IV medication:

• opioid agonist (morphine or fetanyl), opioid agonist-antagonist (nubain- nalbuphine hydrochloride or butorphanol tartrate)

  • relief of severe, persistent or recurrent pain

  • can cause CNS depression

  • can cause respiratory depression

  • can decrease fetal HR

• only used in early stages to prevent respiratory depression in newborn

  • given 4 hours or more before delivery

What is an epidural?

Regional anesthesia.

• spinal block- short acting, one injection directly into spinal fluid, can last up to 2 hrs

• epidural- longer acting, catheter inserted into epidural space to allow continuous anesthesia

Combined Spine/Epidural (CSE)(most common)

• uses local anesthetic, and then insertion of epidural catheter that can be controlled by a PCA

Complications of an Epidural?

• Decreased BP

• Fetal respiratory depression

Treat by hyperoxygenation with 8-10L, give fluids, turn on side.

External Monitors

Able to ambulate, can be used for intact or ruptured membranes.

• Transducer measures fetal heart rate

• Tocodynamometer measures contractions

Internal Monitors

Rupture of membrane required.

• Fetal scalp electrode monitors fetal heart rate

• Intrauterine pressure catheter monitors contractions

4 specific criteria must be met to have these place:

1. ROM

2. at least 2cm dilated

3. presenting part low enough

4. skilled provider to place

Baseline for Fetal Monitoring

• Normal FHR baseline should be between 110-160bpm

• Need at least 10 mins on monitoring and 2 mins of consistent baseline tracing to determine baseline

Why is reactive tracing the gold standard?

• Determines if the baby is well oxygenated.

• This is when FHR has normal baseline with moderate variability and 2 or more accelerations in a 20 min period.

• Minimum timeframe for FHR monitoring is 20 min

Variability

Normal fetal heart rate irregularities in cardiac rhythm.

Accelerations of FHR

Okay, means good O2 reserve for fetus.

Early Decelerations

Usually benign, no treatment needed.

• Mirror contractions

• Caused by head compression

Variable Decelerations

• Caused by cord compression

• Vary from 1 to the next contraction; “U” or “V” shaped.

• Treatment: turn mom side to side; amnioinfusion.

IT IS BAD WHEN THEY ARE PERSISTENT!!

Late Decelerations

BAD!!! need STAT attention. Decels start late in contraction.

• Caused by uteroplacental insufficiency.

• Non-reassuring

• Requires intervention

What are interventions for Late Decels?

• Position pt. into left-lateral position

• Start IV or increase IV fluids

• Discontinue oxytocin (pitocin)

• Notify provider

• Prepare to assisted vaginal birth or c-section

Nursing Interventions for Fetal Distress?

• Maternal position change (place on left side)

• Discontinue oxytocin

• Give 8-10L O2 by mask

• Increase IV rate to improve hydration

• Amnioinfusion can sometimes relieve cord compression

• Assist provider to expedite delivery

Precipitous Delivery

Rapid delivery.

• labor progresses so rapidly (less than 3 hrs)

• Stay calm

• Control the delivery of the head by supporting perineum

• Get help from other staff; call provider

What are ways to expedite delivery?

• Amniotomy

• Forceps

• Vacuum extraction

• C-section

Passageway complications during Labor?

• Abnormal size or shape of pelvis

• Cephalopelvic disproportion (CPD)

• Should dystocia:

  • Head delivers but not the shoulders; can be related to size of fetus.

  • Signs include slow progress, or increasing formation of caput succedaneum

  • Treat with McRobert’s maneuver

Passenger Complications?

• Fetal malposition

  • most difficult is occiput posterior (OP)

• Fetal malpresentation: shoulder, breech, face, or any other part other than vertex

• Fetal distress

• Prolapsed cord: cord comes out before presenting part

• Multiple gestation

What are the signs of placental separation?

• a rise in the fundus of the abdomen

• the umbilical cord lengthens

• a sudden trickle or spurt of blood from the vagina

• uterus changes to a globular shape

  • “Shiny Shultz”

    • side facing baby is shiny and delivered first

  • “Dirty Duncan”

    • the side attached to the uterine wall is delivered first

Alcohol effects on pregnancy

Spontaneous abortion, inadequate weight gain, IUGR, FASD

Caffeine effects on pregnancy

Vasoconstriction and mild diuresis in mother; fetal stimulation

Nicotine effects on pregnancy

Vasoconstriction, reduced uteroplacental blood flow, decreased birth weight, abortion, prematurity, placental abruption, fetal demise

Cocaine effects on pregnancy

Vasoconstriction, gestational HTN, placental abruption, abortion, CNS defects, IUGR

Marijuana effects on pregnancy

Anemia, inadequate weight gain, “amotivational syndrome”, hyperactive startle reflex, newborn tremors, prematurity, IUGR

Opiates and Narcotics effects on pregnancy

Maternal and fetal withdrawal, placental abruption, preterm labor, premature rupture of membranes, perinatal asphyxia, newborn sepsis and death, intellectual impairment, malnutrition.

Sedatives effects on pregnancy

CNS depression, newborn withdrawal, maternal seizures in labor, neonatal abstinence syndrome, delayed lung maturity