week 8: more labor and delivery + review

Factors Affecting Labor: Passenger

• related factors

• who is the passenger

• fontanels

• molding

• fetal presentation

• cephalic presenting part

• breech presenting part

• shoulder presenting part

• Cephalopelvic disproportion

Passenger: Fetus

 Size of the Fetal Head

 Bones in the fetal skull

 Fontanels: Soft spot on the top of the baby’s head

 Molding: the natural, temporary reshaping of a baby's soft skull bones as they overlap to navigate the birth canal during labor

 Fetal Presentation: the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor

 Cephalic – presenting part is the occiput (back of the head) (called “vertex”)

 Breech – presenting part is the sacrum

 Shoulder – presenting part is the scapula

 Cephalopelvic disproportion – head is too big to fit through the pelvis OR the pelvis is too small to accommodate the fetal head.

Factors Affecting Labor: Passenger (fetus)

• fetal lie

• fetal attitude

 Fetal Lie: the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother

 Longitudinal: Ideal position

 Transverse

 Fetal Attitude: the relation of the fetal body parts to one another

Factors Affecting Labor: Passenger (fetus)

• fetal position

• position is denoted by

• best position

• fetal station

• engagement

 Fetal Position: relationship of a reference point on the

presenting part to the four quadrants of the mother’s

pelvis

 Position is denoted by a three-part letter

abbreviation

• best position is LOA

 Fetal Station: measure of the degree of descent of the

presenting part of the fetus through the birth canal

 Engagement: usually corresponds to 0 station

Factors Affecting Labor: Powers, Position and Psychologic

• powers

• primary powers vs secondary powers

• bearing down

• Valsalva maneuver

• position

• psyche

Powers

• Primary powers: contractions

• Frequency, duration, intensity

• Effacement

• Dilation

• Secondary powers: bearing-down efforts: strong urge to bear down, or 'push', Valsalva maneuver: a breathing technique performed by attempting to exhale forcefully against a closed airway

Position of laboring woman

Psychologic state of laboring woman

Labor

• define

• signs of preceding labor

• onset of labor

Labor: process of moving fetus, placenta, and membranes out of the uterus and through the birth canal

Signs preceding labor

 Lightening or dropping

 Bloody show

Onset of labor

 Many factors involved; Cannot be ascribed to a single cause

mechanisms of labor

• define

• 7 Cardinal Movements of Mechanism of Labor (in order)

1. Engagement

2. Descent

3. Flexion

4. Internal rotation

5. Extension

6. External rotation (also called Restitution)

7. Expulsion

Pain During Labor and Birth

• pain defined

• Neurologic Origins

• Expression of pain

Pain: is a highly individualized phenomenon with sensory

and emotional components

Neurologic Origins

 Visceral: Pain from internal organs. It is usually dull, aching, or cramping and hard to pinpoint exactly where it is.

 Somatic: Pain from skin, muscles, bones, or tissues. It is usually sharp and well localized, meaning you can point right to where it hurts.

 Perception of pain

 Many factors influence how one copes with pain

Expression of pain

 Physiologic reactions

 Sensory or emotional reactions

Factors Influencing Pain Response

 Physiologic Factors

 Culture

• Nurse must understand how culture mediates the response to pain

 Anxiety

 Previous Experience

 Comfort

 Support

 Environment

Nonpharmacologic Pain Management: Methods for preparing for labor and birth: Relaxing and Breathing Techniques

Focusing and Relaxation Techniques

 Breathing Techniques:

• Slow breathing

• Quick breathing

• Patterned breathing

 Effleurage and Counterpressure

 Touch and Massage

 Application of Heat and Cold

Nonpharmacologic Pain Management: other

 Acupressure and Acupuncture

 Transcutaneous Electrical Nerve Stimulation (TENS)

 Water Therapy (Hydrotherapy)

 Intradermal Water Block

 Aromatherapy

 Music

 Hypnosis

Pharmacologic Pain Management: sedatives

• define

•  Barbiturates

   Phenothiazines

   Benzodiazepines

 Sedatives: relieve anxiety and induce sleep; may be given to a woman experiencing a prolonged early phase of labor when there is a need to decrease anxiety and promote sleep.

 Barbiturates – rarely used in obstetrics

 Phenothiazines - rarely used in obstetrics

 Benzodiazepines – when given with an opioid analgesic, pain relief is enhanced, and nausea and vomiting are reduced

Pharmacologic Pain Management: Anesthesia & analgesia

• anesthesia

• analgesia

 Anesthesia encompasses analgesia, amnesia, relaxation, and reflex activity. the temporary loss of all physical sensation, including pain, often accompanied by loss of consciousness

 Analgesia: the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness or total feeling

 The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned.

Pharmacologic Pain Management:

• Systemic Analgesia

• Nerve Block Analgesia and Anesthesia

 Systemic Analgesia: Opioids readily cross the placenta; effects on the fetus and newborn can be profound; their analgesic effect in labor is limited

 Opioid (narcotic) antagonists (Narcan)

 Nerve Block Analgesia and Anesthesia: used to produce sensory blockade and various degrees of motor blockade over a specific region of the body

 Local Perineal Infiltration Anesthesia

 Pudendal Nerve Block

 Spinal Anesthesia (Block)

• Post–dural puncture headaches

• Epidural blood patch

Pharmacologic Pain Management: Epidural

• Epidural Anesthesia or Analgesia (block):

• Combined spinal-epidural (CSE) analgesia:

 Epidural Anesthesia or Analgesia (block): currently the most effective pharmacologic pain relief method for labor

 Effectively relieves the pain caused by uterine contractions but does not completely remove the pressure sensations

 Advantages and Disadvantages

 Combined spinal-epidural (CSE) analgesia: sometimes referred to as a “walking epidural,” although women often choose not to walk because of sedation and fatigue, abnormal sensations in and weakness of the legs, and a feeling of insecurity

 Epidural and Intrathecal (spinal) opioids

Contraindications to subarachnoid and epidural blocks

• Epidural Block Effects on Newborn

 Active or anticipated serious maternal hemorrhage

 Maternal hypotension

 Maternal coagulopathy

 Infection at the injection site

 Increased intracranial pressure

 Allergy to the anesthetic drug

 Maternal refusal or inability to cooperate

 Some types of maternal cardiac conditions

 Epidural Block Effects on Newborn

• No evidence that it has a significant effect on the child's later mental and neurologic development

Pharmacologic Pain Management

• Nitrous oxide for analgesia

• General anesthesia

Nitrous oxide for analgesia

 Nitrous oxide mixed with oxygen can be inhaled in a low concentration (50% or less) to provide analgesia during labor and birth.

General anesthesia

 Rarely used for uncomplicated vaginal birth

 The woman should be premedicated with (clear) oral antacid to neutralize the acidic contents of the stomach.

 Because of this risk for neonatal narcosis, it is critical that the baby be delivered as soon as possible after inducing anesthesia, to reduce the degree of fetal exposure to the anesthetic agents and the CNS depressants administered to the mother.

Pain Assessment During Labor and Birth

• when should a pain scale be done

• what should it also evaluate

 A pain scale is often used to evaluate a woman’s pain before and

after interventions are implemented.

 Pain assessment should also evaluate her ability to cope with labor and her overall satisfaction with the labor and birth experience.

Fetal Heart Rate Patterns: baseline FHR

• variability

• 4 possible categories of variability:

Variability

• Described as irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater

4 possible categories of variability:

 Absent

 Minimal

 Moderate

 Marked

Fetal Heart Rate Patterns

 Tachycardia:

 Bradycardia:

 Periodic changes

 Episodic

 Accelerations

 Tachycardia: >160 beats/min  10 minutes or more

 Bradycardia: <110 beats/min  10 minutes or more

 Periodic & Episodic Changes in FHR

 Periodic changes occurring with Uterine contractions

 Episodic (nonperiodic changes) not associated with uterine contractions

 Accelerations: Considered an indication of fetal well-being

Periodic & Episodic Changes in FHR

 Decelerations may be

Early decelerations caused by

Late decelerations caused by

Variable decelerations caused by

Prolonged decelerations defined

 Decelerations – may be benign or abnormal

Early decelerations in response to fetal head compression

Late decelerations due to uteroplacental insufficiency

Variable decelerations due to umbilical cord compression

Prolonged decelerations - lasting more than 2 minutes but less than 10 minutes

Fetal Heart Rate Categories: Category I (normal)

• baseline FHR normal range

• Baseline fetal heart rate variability

• late or variable decelerations

• early decelerations

• accelerations

 Baseline FHR in the normal range of 110-160 beats/min

 Baseline fetal heart rate variability: moderate

 Late or variable decelerations: absent

 Early decelerations: may be present or absent

 Accelerations: either present or absent

Fetal Heart Rate Categories: Category II ( indeterminate)

baseline FHR

Baseline fetal heart rate variability

late or variable decelerations

accelerations

decelerations

 Bradycardia not accompanied by absence of baseline variability

 Tachycardia

 Minimal or absence of baseline variability not accompanied by recurrent decelerations

 Marked baseline variability

 No accelerations in response to fetal stimulation

 Periodic or episodic decelerations

Fetal Heart Rate Categories: Category III (abnormal)

baseline FHR associated with…

Baseline fetal heart rate variability

decelerations

 Nonreassuring FHR patterns associated with fetal hypoxemia

 Hypoxemia can deteriorate to severe fetal hypoxia

 Absence of baseline variability

 Recurrent or late decelerations

 Bradycardia

Nursing management of abnormal patterns

• The five essential components of the FHR tracing that must be evaluated regularly are

• intrauterine resuscitation & process

The five essential components of the FHR tracing that must be evaluated regularly are:

• baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time

intrauterine resuscitation: If any component is abnormal, corrective measures must be taken immediately to improve fetal oxygenation

 Assist woman to a side-lying (lateral) position

 Increase maternal blood volume by increasing the rate of primary IV infusion

 Routine use of oxygen supplementation in individuals with normal oxygen saturation for fetal intrauterine resuscitation is not recommended

FHR Monitoring: Care Management: Other Methods of Assessment and Intervention: Assessment Techniques

 Fetal scalp stimulation and vibroacoustic stimulation

 Umbilical cord acid-base determination

 Fetal scalp blood sampling

 Amnioinfusion

 Tocolytic therapy

 Client and Family Teaching

 Documentation

Deceleration: cause and what to do

early

variable

late

Traditionally first stage of labor dilation by phase

• latent phase

• active phase

• transition phase

Traditionally, the first stage of labor was

considered to be composed of three

phases

 Latent phase (up to 3 cm of dilation)

Active phase (4 to 7 cm of dilation)

Transition phase (8 to 10 cm of dilation)

 However, these definitions have changed based on research findings

New definition of the First Stage of Labor

• how many phases

• define each phase

 NOW, divided into only two phases:

1. Latent Phase - extends from the onset of labor,

characterized by regular, painful uterine contractions that

cause cervical change, to the beginning of the active phase,

when cervical dilation occurs more rapidly. 1-5cm

2. Active Phase - defined as the period during which the greatest rate of cervical dilation occurs, which begins at 6 cm, and ends with complete cervical dilation at 10 cm

First Stage of Labor: Care Management

• how to determine if it is a true labor (3)

• Obstetric triage and EMTALA

Determination of whether the woman is in true labor or false labor

 Contractions

 Cervix

 Fetus

Obstetric triage and EMTALA

 Emergency Medical Treatment and Active Labor Act

 A pregnant woman presenting to an obstetric triage area is presumed to be in “true” labor until a qualified HCP certifies that she is not.

supportive care during first stage of labor

• supportive care includes

• labor supported by

Supportive care during labor and birth: emotional support, physical care and comfort measures, and advice/information.

Labor Support by:

• Nurse

• Father or Partner

• Doulas

• Grandparents

• Siblings during labor and birth

membrane Rupture in absence of uterine contractions

• PROM

• PPROM

• prolonged rupture of membranes

Second Stage of Labor

• begins with what

• what happens

• complete what

• also called the ___ stage

• end with

 Infant is born

 Begins with full cervical dilation (10 cm)

 Complete effacement

 The “pushing” stage

 Ends with infant’s birth

Second Stage of Labor

• how many phases

• define each phase

• Ferguson reflex:

 Two phases

 Latent: sometimes referred to as delayed pushing, laboring down, or passive descent; relatively calm with passive descent of baby through birth canal. the uterus to push the baby down naturally without active maternal pushing right away.

 Active: pushing and urge to bear down

 Ferguson reflex: activated when the presenting part presses on the stretch receptors of the pelvic floor. stimulates the release of oxytocin from the pituitary gland, Leading to stronger uterine contractions and an involuntary, natural urge to push (bear down)

Second Stage of Labor: Care Management: Preparing for birth

• maternal position: western

• what position shortens labor

• bearing down

• valsalva maneuver

 Maternal position: supine, semi recumbent, or lithotomy positions are still widely used in Western societies despite evidence that an upright position shortens labor

 Bearing-down efforts: mom is actively pushing

 Valsalva maneuver: Forceful holding of breath while pushing, increase intra-abdominal pressure and help expel the baby.

 Fetal heart rate and pattern

 Support of Partner

 Supplies, instruments, and equipment

Second Stage of Labor:

• most common birthing position

• Nuchal cord

• Crowning

• episiotomy

• what is no longer recommended

• skin to skin

• lotus birth

most common birthing position: Lithotomy position

Nuchal cord: occurs when the umbilical cord wraps around a fetus's neck

Crowning: The moment when the baby’s head is visible at the vaginal opening and will not retract between contractions.

episiotomy: A surgical incision made in the perineum (the area between the vagina and anus) to enlarge the vaginal opening for delivery.

• Routinely suctioning the newborn’s mouth and nose on the perineum is no longer recommended

skin to skin: Placing the newborn directly on the mother’s bare chest immediately after birth, often covered with a blanket.

Lotus Birth: Leaving the umbilical cord and placenta attached to the baby until it naturally falls off (usually 3–10 days).

Perineal lacerations

• first degree

• second degree

• third degree

• fourth degree

 First degree: laceration that is confined to the skin

 Second degree: laceration that extends into the perineal body

 Third degree: laceration that involves injury to the external anal sphincter muscle

 Fourth degree: laceration that extends completely through the anal sphincter and the rectal mucosa

Third Stage of Labor

• define

• active vs passive management

• passive management: the placenta is expelled within how long

• signs of placental sepration

 Birth of the baby until the placenta is expelled

 The third stage is generally by far the shortest stage of labor

 Passive versus active management:

• Active management: Using medications and controlled traction to deliver the placenta quickly and prevent bleeding.

  Passive (expectant) management: Waiting for the placenta to deliver naturally without interventions.

 When passive management is practiced, the placenta is usually expelled within 15 minutes after the birth of the baby

 Signs of placental separation include lengthening of the umbilical cord and a gush of blood from the vagina.

 Vaginal fullness

 Placental examination and disposal

 Cultural preferences

Fourth Stage of Labor

• define

• care management

• signs of potential problems

• care of family

•  Begins with the expulsion of the placenta

  and lasts until the woman is stable in the

  immediate postpartum period, usually

  within the first hour after birth

• Care management

   First 1 to 2 hours after birth

   Assessment of maternal physical status

   Physiologic changes to prepregnancy status

  Signs of potential problems

   Excessive blood loss

   Alterations in vital signs and consciousness

   Care of the new mother

  Care of the family

   Family-newborn relationships

Obstetric Emergencies

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to:

 a. Facilitate maternal-newborn interaction

 b. Stimulate the uterus to contract

 c. Prevent neonatal hypoglycemia

 d. Initiate the lactation cycle

B