OB Labor and Birth Part 2

What is gait control theory?

States that sensory nerve pathways that pain sensations use to travel to the brain will only allow a limited number of sensations to travel at any given time.

By sending alternating signals through these pathways, the pains signals can be blocked from ascending the neurologic pathway and inhibit the brain's perception and sensation of pain

What position changes can the patient be placed into during labor?

Upright

Ambulating

Lateral (left/right)

Semi-recumbent

Hands and knees

Squatting

Sitting- birth ball, rocker, toilet

What are cognitive strategies for pain relief?

Education

Patterned breathing

Lamaze

Doulas

Hypnosis

Biofeedback

What are sensory strategies for pain relief?

Aromatherapy

Breathing techniques (paced patterned breathing* be aware of hyperventilation)

Imagery

Music

Use of focal points

Subdued lighting

What are cutaneous strategies for pain relief?

Therapeutic touch/effleurage

Walking/Rocking

Counter pressure

Heat or cold packs

TENS therapy

Hydrotherapy

Acupressure

Frequent expectant position changes

What are the side effects of opioids in labor?

ALWAYS CHECK CERVIX PRIOR TO GIVING ANY TYPE OF MED IN LABOR

Common side effects: drowsiness (fall risk), respiratory depression, N/V

Cannot be given in active/transitional phase of labor = fetal respiratory depression

What is nitrous oxide?

Laughing gas

Considered a PCA (patient controlled analgesic)

Patient inhaled gas during contractions

Short half life (does not stay in maternal system/fetal system long <60 seconds)

What is an epidural/spinal anesthesia?

Catheter placed in epidural space of the spinal column

Meds given via catheter on pump-typically fentanyl and bupivacaine

Baseline NST required prior to procedure (ensure baby is stable/fetal well being)

May prolong the second stage of labor due to difficulty pushing

What is nursing care when a patient has an epidural?

Strict bedrest (high fall risk)

Frequent position changes (in bed)

EFM

Blood pressure monitoring, #1 adverse effect is maternal hypotension

If this happens, position change first followed by IV fluid bolus and IV vasopressor admin

What are the complications of epidurals?

Ineffective or partially effective

Maternal hypotension

CSF leak-epidural headache

Infection at insertion site

Dislodgment

Systemic toxicity- local anesthetic systemic toxicity (LAST) can occur with intravascular administration of a local anesthetic

What are pudendal nerve blocks?

Local anesthetic to the the pudendal nerve through the vaginal wall with a needle

Effective pain relief to the vaginal/perineal areas during 2nd stage (pushing)

What are the complications of pudendal nerve blocks?

Hematoma

Infection

Nerve injury

Systemic toxicity

What is an amniotomy?

Manually rupturing the amniotic sack-amni hook

AROM: artificial rupture of membranes

What is the nurses role during an amniotomy?

Assist

Priority: assess FHR

Note time of rupture

Quality of amniotic fluid (clear, bloody, meconium stained)

Odor of amniotic fluid

Complications: umbilical cord prolapse

What should internal monitoring show during labor?

Membranes must be ruptured

What should fetal scalp electrodes (FSE) show during labor?

Small device that is inserted in the layer of skin on the baby's head

Provides continuous EFM

What is an intrauterine pressure catheter (IUPC) and its purpose?

Measures strength of contractions

Inserted into uterus next to baby

Also used for amnioinfusion

What is expected in labor during the transition stage (8cm-10cm)?

Cervix completes dilation and effacement

Contractions are strong and regular (Q 1-3mins X90 sec)

Continued scant amount of pink discharge

Possible spontaneous rupture of membranes (SROM)

Pelvic pressure

Urge to push/have BM

Lasts on average less than 2 hours

What are the physical symptoms of the transition stage of labor?

Shaking

Sweating

Nausea/Vomiting

What is the maternal affect in the transition stage of labor?

Completely focused on contractions

Panic

Out of control feeling

What support may be needed during the transition stage of labor?

Active support

Breath coaching

Position changes

Encouragement and praise

Reassurance

Encourage panting if patient expresses need to push before full dilation

What is the second stage of labor?

Time to push!

Contractions may space out Q2-3 mins X60-90 seconds

"Ring of Fire" burning sensation as head is delivered

Nullip: <3 hours

Multip: <2 hours (typically less than 1 hour)

What are the physical symptoms of the second stage of labor?

Nausea/Vomiting

Sensation of needing to have a BM- increased rectal pressure

What is the maternal affect during the second stage of labor?

Full focus on pushing

Resting between contractions

May vocalize while pushing

What support may be needed during the second stage of labor?

Active support

Coaching pushing effort

Encouragement and praise

Offering PO hydration

Physical support:

Holding a leg, Assisting into different positions, Tug of War, Birthing Bar

What care may be needed in the second stage of labor for a patient with an epidural?

** Epidurals can increase pushing times

Laboring down:

Delay active pushing once fully dilated to allow the baby to descend further into birth canal (via strength of contractions)

Active pushing begins from a closer station

What nursing care is required during birth?

Monitor EFM

Prepare delivery equipment and newborn warmer (resuscitation equipment)

Provide support and coaching:

-pant to ease delivery, open/closed glottis pushing, non=pharm comfort

Notify provider of progress

Document

Admin Meds

Vital Signs

Immediate newborn care

What is assisted birth/operative birth?

Forceps-assisted delivery

Vacuum-assisted delivery

Episiotomy:

-incision made in the perineum to enlarge the vaginal opening

-Facilities/hastens birth

-can minimize soft tissue damage

What is the third stage of labor?

Birth of baby to delivery of placenta

Uterus will continue to contract causing detachment of placenta

Signs of detachment:

-cord lengthening

-change in uterine shape (palpation)

-gush of blood

-urge to push again

Less painful-cramping

What are the physical symptoms of the third stage of labor?

Shaking

What is the maternal affect in the third stage of labor?

Range of responses: elation to exhaustion

Focused on baby

What support may be needed during the third stage of labor?

Promote initial bonding (skin to skin)

Family support

-support person cutting umbilical cord

What is immediate newborn care?

Dry and stimulate infant

Clear respiratory tract first

Keep warm with dry blanket/towel/hat-reduce evaporative heat loss

PLace skin to skin

Assign APGAR scores at 1 and 5 minutes

What is the appearance scale for APGAR?

0- blue and pale

1- body pink, limbs blue

2- all pink

What is the pulse scale for APGAR?

0- absent

1- less than 100

2-more than 100

What is the grimace scale for APGAR?

0-no response

1- grimace

2- coughing and crying

What is the activity scale for APGAR?

0- Limp

1- Weak

2- Strong

What is the respiration for APGAR?

0-Absent

1- Irregular, slow

2- Good, crying

What is the fourth stage of labor?

Immediate postpartum-first 4 hours

Some uterine cramping will continue

Prevents bleeding

Uterus begins to return to normal size

What are the physical symptoms of the fourth stage of labor?

Exhaustion

Hunger

What is the maternal affect of the fourth stage of labor?

Range of responses: elation to exhaustion

May report pain

What is the support for the fourth stage of labor?

Promote initial bonding (skin to skin)

Promote early breastfeeding

Peri packs

Ice packs

Peri-pads

What is immediate postpartum care?

Documentation

Postpartum Vitals (q 15 min X4, q30 ming x2)

Admin Pitocin

Assist with perineal repair

Discontinue/remove epidural per policy

Calculate blood loss

Assess umbilical cord