Labor 1 powerpoint

5 P’s of Labor

Power, Passageway, Passenger, Psyche, Position

Types of Power

Primary power and Secondary Power

What is primary power

Involuntary uterine contractions that originate in the upper two-thirds of the uterus and apply downward pressure on the fetus, causing cervical dilation and effacement

What is secondary power

Voluntary uterine contractions that occur after full cervical dilation that should be timed with primary power

What does Oxytocin do

Augments/Induces uterine contractions

Define Tachysystole

>5 contractions in 10 minutes

How are contractions assessed?

Frequency, duration, and intensity

What is passageway

The passage that the fetus goes through to be birthed

What are the 4 types of passageways

Gynecoid, Anthropoid, Android, Platypelloid

Describe a Gynecoid pelvis

Circular, most ideal for vaginal birthDes

Describe an Anthropoid pelvis

Oval-shaped vertically, generally favorable

Describe an Android pelvis

heart-shaped, less favorable

Describe a platypelloid pelvis

Flat, oval-shaped horizontally, least favorable

Define fetal position

The relationship of the presenting parts of the fetus to the ischial spines

Occiput: Occipital Lobe leads

Mentum: Chin Leads

Anterior/Posterior: The part of the pelvis the leading part is on

Right/Left: The direction that the part is pointing in

What would a -3 station mean

The fetus is floating in the uterus

What would a 0 station mean?

The fetus level with ischial spines

What would a +3 station mean?

The fetus is crowning at the cervix

How does the fetus’ head move through the cervix

The soft fontanels allow the skull bones to overlap to adapt to the birth canal

What is fetal presentation

Which part of the fetus enters the pelvis first

What is a cephalic/vertex presentation

Head first, well-flexed, most favorable

What is a breech presentation?

When the fetus presents butt or feet first

Frank: Butt first, hips flexed and feet by the head

Complete: Hips not flexed all the way, feet and butt first

Footling: One or both feet first

What is a shoulder/transverse presentation?

Arm/Shoulder first

What is fetal attitude?

The relationship of the fetal body parts to each other

(Ideal: well-flexed)

Fetal Lie

The relationship of fetal spine to maternal spine

Longitudinal = Parallel

Transverse = Perpendicular

What position is this

Right Occiput Anterior

What position is this

Left occiput anterior

What position is this

Right mentum posterior

What position is this

Left mentum anterior

What position is this

Right mentum anterior

What position is this

Left occiput posterior

What position is this

Right occiput posterior

How does Psych plan into labor

Anxiety + Stress decrease contractions

Relaxation + Support help pts feel less anxiety and stress

What role does the maternal Position play in labor?

Many things can help progress labor like standing, walking, squatting, a peanut ball, and hands-and-knees position

Premonitory Signs of labor and what they mean

Lightening - The fetal head descends into the pelvis

Bloody Show - Bright red/pink mucus released as the cervix ripens and mucous plug releases

Increased Braxton-Hicks Contractions - drink water and move

GI Issues - N/V, Heartburn and increased urinary frequency due to organ displacement

Nesting Impulse - A surge of energy to put things together/clean

Weight Loss 1-3 lbs. before labor

True Labor Signs

Contractions become regular, progressive, and increase in duration, frequency, and intensity that are not relieved by walking

SROM - note the color, odor, and amount

Cervical dilation and effacement

What is the one thing that confirms labor is present

Cervical dilation and effacement noted on exam

What to assess for immedietly with SROM

cord prolapse, check FHR immediately

What is the first stage of labor?

From the start of labor to full cervical dilation and effacement

What are the phases in the first stage of labor

Latent Phase: 0-6 cm dilated

Active Phase: 6-10 cm dilated

Transition Phase: 8-10 cm dilated

Describe the Latent Phase of the First Stage of Labor

Longest phase of labor, contractions are mild/moderate, patient is communicative

Describe the active phase of the first stage of labor

Contractions every 2-5 minutes, lasting 45-60 seconds, moderate to strong intensity, patient becomes focused and possibly anxious

Describe the transition phase of the first stage of labor

Shortest phase, most intense; contractions every 1-2 minutes lasting 60-90 seconds; patient may feel out of control, irritable, nauseated; nurse never leaves patient and frequently reassess cervix

What is the second stage of labor

Starts with full cervical dilation and ends with the birth of the baby

Patient gets urge to push

May last 30 minutes to 3+ hours

Cardinal Movements of Labor (Every Damn Fetus Is Extremely Eager to Exit)

Engagement: 0 station

Descent: Fetus moves past ischial spines

Flexion: Chin-to-chest flexion due to pressure

Internal Rotation: head rotates to align with maternal outlet

Extension: Head born as neck arches and chin comes off chest

External Rotation: head rotates as shoulders align

Expulsion: Birth of Baby

What is the third stage of labor

Starts from the birth of the baby and ends with the expulsion of placenta

Should last no longer than 30 minutes

How does placental expulsion occur in a vaginal delivery

The uterus continues to contract after birth of baby, separating the placenta from the decidua of the uterus, and the placenta is expelled

Sign of Placental Separation

Gush of blood, umbilical cord extends, uterus firms and rises

If the third stage lasts longer than 30 minutes

Retained placenta, increases hemorrhagic risk and may require surgical removal

What helps decrease the risk of PPH

Uterine contractions

What is the fourth stage of labor

The Recovery Stage (From the expulsion of placenta to 4 hours postpartum)

Vitals every 15 min for the first hour, then every 30 min

Where should fundus be about an hour after birth

At Umbilicus

How many cm does the fundus lower and for how long postpartum

1 cm every day until Day 10 when the uterus goes under the pelvis bone and is unpalpable

What is the #1 cause of PPH and what is the first-line interventions

Uterine Atony; fundal massage and oxytocin

What to assess for upon admission to L&D

Obstetric History: G/P, EDD, GBS status, prenatal labs

Review prenatal risk factors

Confirm allergies and current meds

Assess frequency, intensity, and duration of contractions

Sterile Vaginal Exam: Assess dilation, effacement, station, presentation, position

Assess ROM: SROM, PROM, PPROM; assess color, odor and amount

When is a digital vaginal exam contraindicated

Placenta previa, GBS+, STD+

Initial interventions when patient admitted to L&D

Start IV access

Draw Blood for labs

Urinalysis or urine culture

Apply EFM

Baseline Maternal Vitals

Encourage voiding every 2 hours

Ongoing Assessments during Labor

Maternal

• Vitals every 15/30/60 minutes depending on risk and oxytocin

• Temp every 4 hours, then every 2 hours after ROM

• Cervical checks as clinically indicated/patient requested

• Pain assessment + management

• Emotional status + support needs

Fetal

• Continues EFM

• Review EFM strip every 15-30 minutes during first stage

• Review EFM strip every 5-15 minutes during second stage

• Assess baseline FHR, variability, accelerations, decelerations, and document

Labor Progress Assessment

• Contraction frequency, duration, and intensity

• Cervical exams as indicated

• Monitor fluid balance (void if possible, drink fluids)

What are some methods used to assess FHR

Tocodynamometry (EFM)

Fetal Scalp Electrode (internal and rests on fetal scalp)

Intrauterine Pressure Catheter (internal; sits besides fetus and measures contraction intensity)

What are some factors that affect FHR monitoring

Maternal habitus (size), fetal position, and patient position

Baseline FHR

Normal: 110-160

Assessed over a 2 minute window within any 10 minute segment

Variability

Measures fetal oxygenation

• Absent: none

• Minimal: less than 6 bpm

• Moderate: 6 to 25 bpm

• Marked: Greater than 25 bpm

Accelerations

A FHR increase of at least 15 bpm for at least 15 seconds (at or more than 32 weeks)

A FHR increase of at least 10 bpm for at least 10 seconds (less than 32 weeks)

Presence of accelerations are a reliable indicator of fetal well-being

Decelerations

A decrease in FHR; Early, Variable, Late, Prolonged

What does tachysystole cause?

Decreased uteroplacental perfusion

Pain Management Drugs

Fentanyl, Nalbuphine, Butorphanol, Nitrous Oxide

Regional Anesthesia

Epidural

Combined-Spinal Epidural

Patient-Controlled Epidural Administration

Spinal Block

Nonpharmacologic methods for pain

Counter pressure to sacral or back area

Position changes

Hydrotherapy

Hot/Cold Compresses

Massage (promotes oxytocin release)

Nursing Assessment of ROM

Determine time of rupture

Assess fluid

Nitrazine test (strip should turn blue/dark

Ferning

Nursing Priority after ROM

Assess FHR immediately

Check for umbilical cord prolapse on vaginal exam

• If prolapse, place patient in Trendelenburg or knee-to-chest position

What can cause Tachysystole

Oxytocin or prostaglandin administration (mostly)

Spontaneous in multiparous patients

Priority Intervention if in Tachysystole

1) Turn off meds

2) Position in lateral recumbant

3) IV fluid bolus

4) O2 at 10L/min if FHR is nonreassuring

5) consider terbutaline (tocolytic) to relax uterus

6) Call Provider

What to do with GBS positive patients

Administer IV penicillin every 4 hours during labor, at least 4 hours before birth

What to do with PEC/GHTN patients

Continuous EFM required; Mag Sulfate, monitor for toxicity; calcium gluconate at bedside

What to do with GDM/T1DM patients

Continuous EFM; blood glucose monitoring, insulin drip may be required

What to do with VBAC/TOLAC patient

Continuous EFM; risk of uterine rupture; Uterotonics are contraindicated

Signs of Uterine Rupture

Sudden severe pain, FHR change (prolonged deceleration), loss of station