Maternity Exam 2

Factors Influencing the Onset of Labor

• uterine stretch

• progesterone withdrawal

• increased oxytocin sensitivity

• increased release of prostaglandins

Signs of Labor

• lightening

  • 14 days before birth

  • fetus drops into pelvis → easier to breathe, harder to walk

  • increase in braxton-hicks contractions

• bloody show

• weight loss due to increase in loose stools

• nesting

• increased contractions, backache

• change in sleep

• N/V/D

Rupture of Membranes

NEED TO LABOR WITHIN 24HRS OF RUPTURE

GO TO HOSPITAL FOR RUPTURE EVEN WITH NO CONTRACTIONS

fern test = AF alkaline, urine acidic

COAT

COAT

C- color… should be clear, brown/green = meconium → fetal distress

O- odor… foul = infection?

A- amount

T- time… want to deliver within 24hrs

Care for Rupture of Membranes

1ST STEP = MONITOR FHR for DISTRESS

• ROM can cause cord prolapse

Stages of Labor

First Stage = true labor to complete cervical dilation

• Latent Phase = 0-3cm, 0-40%, contractions q5-10min, 30-45sec

• Active Phase = 4-7cm, 40-80%, contractions q2-5min, 45-60sec

• Transition Phase = 7-10cm, 80-100%, contractions q1-2min, 60-90sec

Second Stage = cervix 10cm to birth of baby… PUSHING

Third Stage = birth of infant to placental separation… PUSH OUT PLACENTA

Fourth Stage = 1-4hr following delivery… risk of hemorrhage

First Stage of Labor

Latent Phase

• cervix 0-3cm

• effacement 0-40%

• contractions q5-10min, 15-30sec

• mom feels motivated, need to encourage rest/activity

Active Phase

• cervix 4-7cm

• effacement 40-80%

• contractions q3-5min, 45-60sec

• mom becomes apprehensive/tired… position changes, massage, focus

Transition Phase

• cervix 8-10cm

• effacement 80-100%

• contractions q1-2min, 60-90sec

• IMMENSE PAIN, PANIS, SWEATING

Second Stage of Labor

PUSHING OUT BABY

• “ring of fire”, urination/defecation

• push with contractions, rest in-between

Third Stage of Labor

PUSHING OUT PLACENTA

• mom may not even feel

• signs of placental detachment → change in uterine shape, gush of blood, urge to push again

• monitor for hemorrhage

Fourth Stage of Labor

1-4hrs POST-BIRTH

• uterus contracted to minimize blood loss

• may have shakes, tired, hungry, pain

• NEED TO MONITOR FOR HEMORRHAGE

Signs of Placental Separation

• uterus rises upward

• umbilical cord lengthens

• gush of blood

• uterus changes to globular shape

5Ps of Labor and Birth

Passageway = birth canal

Passenger = fetus + placenta

Powers = contractions

Position = maternal

Psychological Response

Passageway

Pelvic Shape

• gynecoid = favorable for vaginal delivery

• android = male-shaped, not favorable

• anthropoid = adequate

• platypelloid = not favorable

Soft Tissues

• cervix = thins through effacement to allow presenting part to descend

• pelvic floor muscles

• vagina

Sterile Vaginal Exam (SVE) gauges cervical effacement + dilation

Passenger

• fetal skull

• fetal attitude

• fetal lie

• fetal presentation

• fetal position

• fetal station

• fetal engagement

Fetal Skull

• sutures = allow for overlapping + changes in molding

• fontanels = intersections of sutures

• should be soft, sunken = dehydrated, bulging = xs fluid in brain

Fetal Attitude

relationship of fetal body parts to one another

FLEXION = chin 2 chest, arms + legs flexed into torso

EXTENSION = chin away from chest, extremities extended

Fetal Presentation

presenting part of fetus to enter pelvis first

cephalic/vertex = head

breech = pelvis/butt first

shoulder = scapula first

Fetal Lie

relationship between maternal spine + fetal spine

LONGITUDINAL = fetal spine parallel to maternal… breech or cephalic… vertical

TRANSVERSE = fetal spine perpendicular to maternal… shoulder presenting… horizontal

Fetal Position

Landmarks:

• occipital bone (O) = vertex

• chin/mentum (M) = face presentation

• buttocks/sacrum (S) = breech presentation

• scapula/acromion (A) = shoulder presentation

3 Letter System:

• Right (R) or Left (L) → presenting part on what side of maternal pelvis

• Occiput (O), Sacrum (S), Mentum (M), or Scapula (Sc/A) → references presenting part

• Anterior (A) or Posterior (P) → presenting part faces which side of maternal pelvis

Fetal Station

how far the presenting part is into the maternal pelvis

0 = equal with pelvis… ENGAGEMENT

-# = further into mom

+# = beyond pelvis

Powers

CONTRACTIONS

• defined by frequency, duration, intensity

• involuntary → thin + dilate cervix

Psychological Response

factors influencing a positive birth experience:

• clear information

• support

• confidence

• trust in staff

• positive reaction to pregnancy

• control over breathing

• preparation for childbirth experience

MATERNAL Physiologic Responses to Labor

• increased HR, CO, BP during contractions

• increased white blood cell count

• increased RR, O2 consumption

• decreased GI motility

• decreased gastric emptying/pH

• muscle aches/cramps

• decreased blood glucose levels

FETAL Physiologic Responses to Labor

• periodic FHR accelerations and slight decels (early better than late)

• decreased circulation + perfusion

• decreased fetal breathing movements

• slight temperature elevation

External Fetal Monitor

produces a continuous tracing of FHR

goal:

• provide information about fetal oxygenation

• prevent fetal injury

• detect fetal heart rate changes early

Fetal Response to Labor

fetal oxygen supply can DECREASE

• maternal hypertension → chronic or pregnancy-induced

• hypotension → supine maternal position, hemorrhage, epidural analgesia, anesthesia

• hypovolemia → caused by hemmorrhage

• alterations in fetal circulation with compression of umbilical cord

• reduction in blood flow to intervillous space in placenta

FIRST CHOICE IS ALWAYS TO TURN PATIENT POSITION IF MATERNAL/FETAL DISTRESS

Reassuring FHR

• baseline FHR in normal range of 110-160bpm

• no periodic changes and a moderate baseline variability

• accelerations of FHR with fetal movement

Non-Reassuring FHR

• baseline FHR <110 or >160bpm

• decreased baseline

• irregular rhythms

• decreased FHR during/within 30 seconds after a contraction

• fetal tachycardia may indicate infection

External Monitoring

FHR → ultrasound transducer

UC → tocotransducer

Internal Monitoring

Fetal Spiral/Scalp Electrode

IUPC → intrauterine pressure catheter

Guidelines for Assessing FHR

• review Hx for prenatal + labor risks

• intermittent auscultation q15-30min during active labor

• intermittent auscultation q5-15min during stage 2 of labor (pushing)

Criteria for Using Continuous Internal Monitoring for FHR

• ROM and cervical dilation >2cm

• present fetal part low enough to allow placement of scalp electrode (STATION)

HEAD LOW ENOUGH + HOLE BIG ENOUGH

Categories of Baseline Variability

absent = no fluctuations detectable

minimal = fluctuation range <5bpm

moderate = NORMAL, fluctuation range 6-25bpm

marked = fluctuation range >25bpm… fetal distress

Decelerations

early = ok… response to fetal head compression

• HR decreases during contraction, rises when contraction ends

• NO INTERVENTION NEEDED

variables = umbilical cord compression

• reposition mom side to side or knees to chest

late = BAD… uteroplacental insufficiency

• HR decreases after contraction with slow return to baseline

• TURN ONTO LEFT SIDE

Late Decelerations

causes:

• inadequate fetal oxygenation

• maternal hypotension

• placenta previa

• placenta abruptio

• uterine hyperstimulation with Pitocin

• preeclampsia

• post-term pregnancy

• diabetes

nursing interventions:

• CLIENT ON LEFT SIDE

• increase IV fluids

• oxygen

• d/c Pitocin

• elevate legs

• prepare for C/S

Prolonged Decelerations

• FHR below baseline of 15bpm and >2mins

Nursing Care

monitor 5 components of FHR

• baseline → normal should be 110-160bpm, brady <110bpm for 10 mins, tachy >160bpm for 10 mins

• variability → fluctuations around baseline… absent = no fluctuation, minimal <5bpm change, moderate 6-25bpm change, marked >25bpm change

• accelerations → GOOD

• decels → early = ok, variables = ok, late = bad

• changes/trends over time

Nursing Interventions for Variable/Late Decels

• reposition mom onto L side

• IVF bolus

• shut off Pitocin

• oxygen

• notify provider

VEAL CHOP MINE

V- variable decelerations

E- early decelerations

A- accelerations

L- late decelerations

C- cord compression

H- head compression

O- okay

P- placental insufficiency

M- move mother

I- intervention not necessary

N- no intervention needed

E- evaluate for why → stop Pitocin, give oxygen, reposition mom, possible C-section

Category I

Normal

• baseline rate 110-160bpm

• baseline variability moderate

• present or absent accelerations

• present or absent early decelerations

• no late or variable decelerations

Category II

Intermediate

• fetal tachycardia >160bpm

• fetal bradycardia <110bpm not accompanied by absent baseline variability

• absent baseline variability not accompanied by recurrent decelerations

• minimal or marked variability

• recurrent late decelerations with moderate baseline variability

• recurrent variable decelerations accompanied by minimal or moderate baseline variability; overshoots, or shoulders

• prolonged decelerations >2 mins but <10 mins

Category III

Abnormal

• PREDICTIVE OF ABNORMAL FETUS ACID-BASE STATUS

• fetal bradycardia <110bpm

• recurrent late decelerations

• recurrent variable decelerations

• sinusoidal pattern (smooth, undulating baseline)

Visceral Pain

ORGANS

• uterine contraction

• cervical dilation

• first stage of labor → lower abdomen, back, legs

Somatic Pain

MUSCULOSKELETAL

• fetal head pressure

• stretching of pelvic muscles

• perineal tissue stretching

Opioid Analgesics

• rapid onset

• potential effect on fetus → decreased RR, HR

• DO NOT GIVE WITHIN 1HR OF BIRTH

fetal effects:

• decreased HR variability

maternal effects:

• nausea

• vomiting

• respiratory depression

nursing interventions:

• assess RR + FHR

• antiemetics

• safety

Opioids

• stadol = butorphanol

• nubaine = nalbuphine → LOWER RISK RESPIRATORY DEPRESSION

Fentanyl + Morphine

• decreased fetal impact

Naloxone

• opioid antagonist

• may be given as needed to treat opioid induced respiratory depression

Local Anesthesia

perineal infiltration → directly into perineum before birth/episiotomy

pudendal nerve block → no newborn complications

Regional Anesthesia

spinal/intrathecal block:

• single injection into subarachnoid space

• fentanyl, morphine, local anesthetics like lidocaine and bupivacaine

• quick onset

• good for c-sections

• duration 90-120mins

epidural analgesia:

• catheter placement into lumbar epidural space for continuous or intermittent medication delivery

• meds = bupivacaine with or without fentanyl

• administered via PCA prn

contraidications:

• coagulopathy

• unstable spine

• spinal anomalies (spina bifida, scoliosis)

• CNS anomalies (multiple sclerosis, syringomyelia)

• cardiac anomalies (aortic stenosis)

• sepsis or infection around catheter site

• allergy to opioids

• hypovolemia

• increased intracranial pressure

Nursing Care for Epidural

• give bolus fluid 1st to combat hypotension

• monitor vital signs

• patient teaching

Nitrous Oxide

• self-administered

• non-invasive opioid

• patient teaching:

  • inhale at start of contraction

  • side effects

  • decreased effectiveness as labor progresses

General Anesthesia

• emergencies or when spinal not successful

• monitor for complications:

  • allergic reaction

  • sore throat

  • damage to throat, teeth, vocal cords

  • infection in lungs

  • stroke

  • MI

  • postpartum hemorrhage

Preterm Labor (PTL)

labor < 37 weeks

Preterm Birth (PTB)

gestational age at birth < 37 weeks

Preterm Infant

born after 20 weeks + before 37 weeks

Preterm Labor

contraction pattern:

• 4 contractions q20min or 8 contractions q1hr

labs:

• CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length

REGULAR UTERINE CONTRACTIONS WITH CERVICAL EFFACEMENT BETWEEN 20 AND 37 WEEKS

Drugs for Preterm Labor

tocolytics → may prolong pregnancy for 2-7 days while steroids can be given

betamethasone → 2 doses IM for fetal lung maturity

antibiotic prophylaxis for women with GBS

Preterm Labor Risk Factors

• #1 = PREVIOUS PRETERM BIRTH

• infection

• hx miscarriage/abortions

• multifetal pregnancy

• hydramniosis

• age < 17

• age >35

• low SES (socioeconomic)

• smoking

• substance abuse

• IPV

• diabetes

• chronic hypertension

• preeclampsia

• insufficient cervix

• placenta previa

• placental abruption

• PPROM

• short interval between pregnancies

• second trimester bleeding

• low pre-pregnancy weight

Preterm Labor Findings

expected findings:

• uterine contractions → 4 in 1 hour BAD

• pressure in pelvis

• persistent low back pain

• bloody show

• urinary frequency

• GI cramping

• diarrhea

assessment findings:

• increase/change/odor/blood in vaginal discharge

• change in cervical dilation

• regular uterine contractions, frequency q10min or greater, lasting 1hr or longer

• PROM

Preterm Labor Diagnostic Procedures

swab of vaginal secretions for FFN (fetal fibronectin) 24-34wks gestation

• negative = good… not likely to deliver within 10-14 days

measure endocervical length for shortened cervix

uterine activity monitoring

non-stress test

biophysical profile

• respirations

• nst (FHR)

• tone

• measurements

• qualitative AFI

Care for Preterm Labor

• STOP CONTRACTIONS

• modified bedrest

• left lateral position

• pelvic rest

• hydration → dehydration causes brain to release oxytocin + ADH

• identify + treat infection

• temp + tachycardia = suspected chorioamnionitis

Nifedipine

• calcium channel blocker

• monitor for HA, flushing, dizziness, nausea

Magnesium Sulfate

• given for neonatal neuroprotection

• tocolytic (contraction stopper) → relaxes smooth muscle of uterus

• client should notify RN if blurred vision, HA, nausea, vomiting, difficulty breathing

• monitor for MAG TOXICITY:

  • loss of DTRs

  • urine retention

  • respiratory depression

  • pulmonary edema

  • chest pain

• antidote = calcium gluconate

Terbutaline

• beta adrenergic agonist

• RELAXES SMOOTH MUSCLE + INHIBITS UTERINE ACTIVITY

• do NOT give with Hx diabetes/prediabetes, cardiac disease, hypertensive disorders, hyperthyroidism, hemorrhage

• notify provider with HR > 130bpm or BP <90/60 mmHg

• d/c if not tolerated well

Betamethasone

• glucocorticoid

• GIVEN TO ENHANCE FETAL LUNG MATURITY AND SURFACTANT PRODUCTION 24-34wks GESTATION

• MONITOR FOR MATERNAL PULMONARY EDEMA (CP, SOB, CRACKLES), HYPERGLYCEMIA, HR CHANGES

PROM/PPROM

risk factors:

• infection

• prior PTL

• short cervix

• 2nd or 3rd trimester bleeding

• pulmonary or CT disorders

• lower BMI

• tobacco/substance use

• risk for cord prolapse

expected findings + nursing care:

• fluid leaking from vagina

• variable decels + extended decels

• positive nitrazine test → pH

• GBS cultures

• limit vaginal exams

• daily kick counts

• BR with BRP

• ampicillin r/t chorioamnionitis

• betamethasone for fetal lung maturity

Post-term Labor

pregnancy continuing past 42 weeks gestation

maternal risks:

• cesarean birth

• dystocia

• birth trauma

• postpartum hemorrhage

fetal risks:

• macrosomia

• shoulder dystocia

• brachial plexus injuries

• low APGAR

• postmaturity syndrome

• cephalopelvic disproportion

Post-Term Pregnancy Assessment + Management

assessment

• estimated DOB

• daily fetal movement counts

• NST biweekly

• amniotic fluid analysis

• weekly cervical exams

management:

• fetal surveillance

• decision for labor induction

• education + support

Precipitous Labor

LABOR THAT LASTS LESS THAN 3HRS FROM ONSET OF LABOR TO BIRTH

risk factors:

• multipara

• past precipitous birth

assessment findings:

• rapid cervical dilation, hypertonic UCs

potential category II-III FHR

nursing actions:

• prepare for delivery

• stay with patient

• monitor FHR/UC q15min

• sterile vaginal exams

• anticipate emergencies → PPH, lacerations, neonatal hypoxia, CNS depression

Shoulder Dystocia

shoulders get stuck after delivery of the head

risk factors:

• fetal macrosomia

• maternal diabetes

• hx shoulder dystocia

• prolonged second stage

• excessive weight gain

associated risks:

• fetal injury + death

• brachial plexus injury

• fractured clavicle

• maternal lacerations/infection/hemorrhage

assessment findings:

• delay in delivery of shoulders

• turtle sign

management:

• downward traction via suprapubic pressure

• extended midline episiotomy

• McRobert’s maneuver → knees to chest and back out

• Woods Corkscrew maneuver → rotate posterior shoulder 180 degrees to disimpact anterior shoulder

• Zanvanelli maneuver last resort → push head back into pelvis + stat c/s

Tachysystole

TOO MANY CONTRACTIONS THAT BECOME INEFFECTIVE

• 5+ UCs in 10 mins over a 30 min window

• series of single UCs lasting 2+ mins

• UCs occurring within 1 min of each other

Hypotonic Uterine Dysfunction

TOO FEW/TOO WEAK CONTRACTIONS

• uterine contractions cannot effectively dilate cervix

• palpate soft

• occur at a rate of less than 3-4 q10min lasting <50 sec

• treatment = rest, amniotomy, oxytocin

Induction of Labor

DELIBERATE INITIATION OF UCs TO STIMULATE LABOR

indications:

• post-date (>41-42wks)

• prolonged PROM

• oligohydramnios

• fetal growth restriction

• expectant medical conditions (preeclampsia, GDM, cholestasis, AMA)

• fetal demise

• chorioamnionitis

• elective

Cervical Ripening Methods

• prostaglandin E2 gel or Misoprostol/Cytotec → SOTEN CERVIX

• mechanical/physical methods → balloon dilators, amniotic stripping

Amniotomy

• breaking water

• NEED TO CHECK FHR BEFORE, DURING, OR AFTER

Oxytocin

• hormone normally produced by posterior pituitary gland to STIMILATE UTERINE CONTRACTIONS + MILK LET-DOWN

• pitocin (synthetic) may be used to induce labor or augment labor

• watch for contractions that are too strong or > 90 sec and are more frequent than 2-3min → tachysystole

Pitocin

• synthetic oxytocin

• IV drip titrated based on contractions + FHR pattern

• goal = contractions strong to palpation + 2-3mins apart

• D/C FOR FETAL OR UTERINE DISTRESS

Mechanical Dilation

foley or cook’s catheter induction

• catheter inserted up into uterus through cervix → balloon filled with saline → pressure causes manual dilation

• often used at same time with Pitocin

Amniotomy

• need to ensure presenting part is fully engaged into pelvis to avoid cord prolapse (0 station)

• monitor FHR

• treat decels PRN with intrauterine resuscitation

• assess + document COAT of amniotic fluid → color, odor, amount, time

• document time of AROM → want delivery within 24h

• monitor temp q2h r/t infection risk

Trial of Labor After Cesarean (TOLAC)

risk of uterine rupture → scar from previous c/s may not hold

can only try with low transverse incision, not vertical/classical

if an induction, only certain methods may be used:

• Pitocin

• mechanical induction

• NO CERVICAL RIPENING AGENTS

• need IV + continuous fetal monitoring

Fetal Distress

NON-REASSURING FHR TONES → PERSISTENT CAT II/III

need decision for c/s within 5 minutes

Amnioinfusion

CATHETER INFUSION OF NORMAL SALINE INTO UTERUS TO THIN MECONIUM/MOVE CORD/ADD MORE FLUID

indications:

• severe variable decels due to cord compression

• oligohydramnios due to placental insufficiency

• postmaturity

• rupture of membranes

• preterm labor with PPROM

• thick meconium fluid

Meconium Stained Fluid

baby passed stool in utero

risk of aspiration in neonate

Major Placental Abruption/Uterine Rupture

placental sheers off wall of uterus or uterus bursts open

risk of fetal distress/mortality

DIC

Amniotic Fluid Embolism/Anaphylactoid Syndrome of Pregnancy

RARE

an emboli of amniotic fluid in expectant circulation, followed by respiratory distress, coagulation failure, circulatory collapse

HIGH MORTALITY RATE

Prolapsed Umbilical Cord

umbilical cord displaced and comes out of the vagina before presenting part

HIGH CHANCE OF COMPROMISED FETAL CIRCULATION

OB EMERGENCY

nursing responsibilities:

• patient in trendelenburg

• call for help

• get a glove + PUSH PRESENTING PART OFF OF CORD

• need immediate c/s

Operative Vaginal Delivery

vacuum-assisted

forceps-assisted

possible complications:

• cervical lac

• lac to perineum/vagina

• injury to bladder

• baby facial nerve palsy

• facial bruising

• subdural hematoma

Vaginal Lacerations

1st Degree = vaginal mucosa torn

2nd Degree = perineal muscles torn

3rd Degree = anal sphincter torn

4th Degree = rectum torn

Episiotomy

• surgical incision of posterior aspect of vulva made during 2nd stage of labor

• used if patient is at high risk for 3rd or 4th degree tear

• used if expedited delivery is needed r/t fetal compromise

• risk = infection, bleeding, pain

Cesarean Birth

indications:

• expectant → failure to progress, cephalo-pelvic disproportion

• fetal → distress (persistent Cat II/III), multipara, non-cephalic presentation

• pregnancy → placental abruption, uterine rupture, placenta previa, umbilical cord prolapse, eclampsia, HELLP, cervical obstruction, active herpes/syphilis, HIV, hx 2+ c/s

• elective → not recommended for primipara or for hx vaginal deliveries

nursing care:

• prior → assess EFM, vitals, HTT, start IV, draw CBC, consent form, admin meds

• during → positioning for spinal, FHR, compression devices, insert foley cath, TIME OUT

• after → monitor VS, assess for bleeding, check fundus/lochia, treat pain/nausea