Maternity Exam 2

Onset of Labor

• cannot be ascribed to a single cause

• many factors: changes in maternal uterus, cervix and pituitary gland

• decrease in progesterone

• increase in estrogen, prostaglandins and oxytocin

Premonitory Signs of Labor

• lightening

• blood show and increased vaginal discharge

• backache, urinary frequency and pelvic pressure

• mild weight loss and gi upset

• rupture of membranes

• stronger braxton hicks contractions

Lightening

• baby drops lower into the pelvis

• easier breathing, more pelvic pressure

• walking may feel heavier or more uncomfortable

• weeks before labor

Bloody Show & Increased Discharge

• mucus plug discharge, often blood-tinged

• noticeable increase in secretions

• hours to days

Backache, Urinary Frequency & Pelvic Pressure

• persistent lower back pain as baby repositions

• frequent urination as baby descends

• days to weeks before labor

Mild Weight Loss & GI Upsets

• loss of 1-3lbs

• nausea or loose stools

• days before labor

Rupture of Membranes

• sudden gush of fluid

• slow trickle of fluid

• clear or slightly pink in color

• watery or slightly sticky

• odorless

• seek care immediately

Stronger Braxton Hicks Contractions

• practice contractions become more intense

• days to weeks before labor

True Labor

• timing: regular, become closer together

• strength: become stronger with time, typically include vaginal pressure

• discomfort: back to front of the abdomen

• activity: continue regardless of position
  
  regular timing, closer and stronger as progress, no position changes, back to front

False Labor

• timing: irregular, not occurring close together

• strength: weak, no change with time

• discomfort: front of abdomen

• activity: may stop or slow down with walking or making a position change

irregular, no time change, front of abdomen, position changes

5’Ps Affecting Labor and Birth

• passageway - canal

• passenger - fetus and placenta

• powers - contractions

• position of mother

• physiologic response

Passageway

• route through fetus must travel for to be born via the v——-a

• consists of two parts of the woman’s body: the bony pelvis and soft tissue

True Pelvis

• boney passageway through which the fetus must travel

• concists of the inlet, mid pelvis and outlet

• 4 basic types but most pelvis’ are a combination of them

Gynecoid

• round-shaped with wide pelvic inlet

• best for delivery

• less likely for obstructed labor

• 50% of women

Android

• heart shape

• less space in mid

• increase risk of obstructed labor

• need for forceps or c-section

• 20-25% of women

Antropoid

• long-oval shape

• narrow transverse diameter

• long and deep

• possible delivery

• 35-40%

Platypelloid

• very wide transverse diameter

• short anteroposterior diameter

• flat pelvis

• higher risk of difficulty delivery

• < 3% of women

Soft Tissue

• cervix

• pelvic floor muscles

• vagina

Passenger - Fetus

• relationship between fetus & passageway affected by 7 factors:

  • head

  • attitude

  • lie

  • presentation

  • position

  • station

  • engagement

Fetal Head

• largest structure affecting birth

• sutures and fontanelles allow head molding and help identify position

• flexed head allow easier birth

• key diameters: suboccipitobregmatic and biparietal

Fetal Attitude

• refers to the posturing (flexion or extension) of the joints & relationship of fetal parts to one another

• most common - joints flexed, most favorable for birth

• nonflexed = increased difficulty

Fetal Lie

• refers to relationship of spine to spine

• longitudinal - parallel and ideal for labor

• transverse - crosses spine of mother, across abdomen

• oblique - at angle, no presenting part

Fetal Presentation

• part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor

  • cephalic - vertex, military, brow, face

  • breech - buttocks, shoulder

Fetal Position

• describes how presenting part related to maternal pelvis

• presenting: occiput, sacrum, mentum, acromion

• maternal pelvis quadrants: right/left and anterior/posterior

• position is recorded with a 3 letter abbreviation

Passenger: Fetal Position

Landmarks:

• occipital bone - vertex

• chin/mentum - face

• buttocks - breech

• scapula - shoulder

Leopold Maneuvers

• method for determining presentation, position and lie of fetus using specific steps

• involces inspection and palpation of maternal abdomen as screening assessment for malpresentation.

• ask what part located at fundus, on what side fetal back located, what is presenting part and is head flexed and engaged in pelvis

Fetal Station

• relationship of presenting part to the level of the maternal pelvis ischial spine

• measured in cms and is referred to as minus or plus, depending on location above or below ischial spine

• zero is designated when the presenting part is at level of maternal ischial spine

Fetal Engagement

• signifies the entrance of presenting part into the smallest diameter

• said to be engaged when presenting part reaches 0 station

• determined by pelvic exam

• primigravida - occurs 2 weeks before term

• multipara - several weeks or not until labor begins

• floating = engagement not occured and presenting part freely movable above pelvic inlet

• important for cardinal movement of labor

Cardinal Movements

Mechanism: fetal adjustments necessary in human birth

• engagement

• descent

• flexion

• internal rotation

• extension

• restitution and external rotatio

• expulsion

Powers

primary - uterine contractions

primary stimulus powering labor which causes complete dilation & effacement during 1st stage of labor

involuntary and cannot be controlled by patient

parameters - frequency, duration and intensity

Dilation

the thinning (opening) of cervix, 0cm-10cm

Oxytocin

• stimulates the calm and connection

• released in response to touch, security, pleasant sounds, good food, positive thoughts

• responsible for uterine contractions that bring about labor

• also responsible for milk ejection during breastfeeding

Endorphin

• morphine like painkillers

• reduces brain perception, helps give focus

• released in response to touch, deep breathing, rhythmic movement and visualization

• increases in pregnancy, rise in labor and birth

Catecholamine (Adrenaline)

• stress hormone

• pupils dilate, pulse and breathing quicken, muscles ready to move

• can cause contractions to stop in early labor

• increases in second stage of labor and provides energy to push

Prolactin

• milk-producing/mothering hormone

• thought to be important with catecholamine in fetal lung development

Maternal Positions

• upright positions

• gravity helps bring the baby down

• less risk of compressing maternal aorta

• women should be in comfortable position - #2 of healthy birth practices

Psyche

• crucial part of childbirth

• catecholamines secreted in response to anxiety or fear, can inhibit uterine contractility and placental blood flow

• relaxation augments the natural process of labor

5 Additional P’s

• philosophy

• partners

• client preparation

• paing management

• patience

First Stage of Labor

0 to 10

three subphases

Second Stage of Labor

• complete dilation

• 10 cm to birth

• may last up to 3 hours

Third Stage of Labor

• separation and delivery of the placenta

• usually takes 5-10 mins, may take up to 30

Fourth Stage of Labor

• 1-4 hours after birth of the newborn

• time of maternal physiologic adjustment

Assessing the Laboring Patient

• goal: obtain information to form plan of care

• accurate and frequent assessment to ensure health and well-being to mom and fetus

• support, human interaction, teaching to help and support during this time

• assessment at admission and throughout

Nursing Assessment During Labor

• monitor VS

• review prenatal records

• perform vaginal exam

• assess uterine contractions

• perform leopold maneuvers

• analyze amniotic fluid after ROM

Early Phase of Stage 1

• will dilate to 6cm

• contractions 3-40 sec/every 5-20 mins

• fatigue can set in so need to conserve energy

• efacement 0-100%

Active Stage of Phase 1

• will dilate to 8cm

• cervix thinned out and opening up

• 100% effacement

• contractions 45-60 seconds every 2-5 mins

• fetus head facing mother’s side so widest part of head is in widest part of mother’s pelvis

Transitional

• fully dilated and effacted

• contractions 60-90sec/every 2-3 mins

• fetus begins to rotate towards mother’s backbone and tuck chin to chest

Nursing Care 1st Stage of Labor

• monitor VS

• note amniotic fluid color when ruptures

• start IVF if neccesary

• encourage voiding

• encourage rest between contractions

• encourage position changes

• assist with personal comfort

• reduce anxiety

• provide information

• use supportive relaxation techniques

Second Stage of Labor

• pushing phase

  • lamaze 2 and 5: move around throughout labor and avoid giving birth on back/follow urge to push

Second Stage of Labor Nursing Care

• more frequent VS

• help with breathing

• position change'

• provide info

• coach pushing

• answer honestly

• acknowledge concerns

• assist HCP in prep for birth

Assisting with Delivery

• assist HCP and patient

• newborn is no longer suctioned routinely when born

• if vigorous at birth: newborn is placed on mother skin to skin and delayed cord clamping

• if not vigorous at birth: to warmer for further eval

Nursing Care in 3rd Stage

• focus on providing initial newborn care and assisting with birth of placenta

• this is the shortest stage of labor

Physical Changes in Mother

• contractions slow following birth of baby

• shrinking of uterus to grapefruit size, found at level of the umbillicus

• uterus rises up

• the umbilical cord lengthens

• sudden trickle of blood is released from the vaginal opening

• uterus changes its shape to globular

Nursing Care During 3rd Stage of Labor

• HCP gently palpate the uterus while waiting for signs of placental seperation from uterine wall

• nurse continues to assist patient and HCP

• mother asked to bear down to expel placenta

• nurse encourages mouth breathing to relax abdominal muscles

Nursing Care During 3rd Stage - Initial Newborn Care for Vigorous Newborn

• perform Apgar scoring at 1 and 5 mins

• perform quick assessment while mother doing skin to skin

• assess vital signs

• provide and maintain warmth

• place ID bracelets on newborn and parents

APGAR

• color

• hr

• relex irritability

• muscle tone

• respiration
  
  10 highest, 0 lowest

After Stabilization or 1 Hour of Bonding

• obtain measurements

• perform head to toe assessment

• monitor vitals

• administer vitamin K and erythromycin eye ointment

• provide info to parents

• document assessments, void and feedings

Nursing Care During 4th Stage of Labor

• basics for postpartum care

• palpate fundus and assess firmness and position

• assess bladder for fullness

• immediate newborn care done at bedside if possible

• change gown and apply maternity pads

• provide heating pads

• ice packs to perineum

• check for sensation return post epidural

• BP and pulses

• assess lochia every 15 mins

• weigh everything for blood loss

• encourage rest

Notify HCP

• hypotension

• tachycardia

• excessive, unrelieved pain

• call if uterus not firm post massage

• excessive or continous bleeding

• temp at or above 100.4

Purposes of Fetal Monitoring

• evaluate fetal condition during pregnancy

• identify possible hypoxic insult

• used to determine need for interventions

Intrapartum Monitoring Types

• intermittent auscultation - done with palpation of uterine activity

• electronic fetal monitoring - done with fetal monitor

Intermittent Auscultation

• Perform Leopold’s maneuvers

• To listen to FHR, use fetoscope or doppler

• Palpate maternal pulse simultaneously

• Count FHR between contraction and determine relationship

• Determine difference between baseline FHR and contraction response

Electronic Fetal Monitoring

• remove surveillance

• ultrasound transducer - on abdomen, records FHR

• toco transducer - on fundus, uterine contractions

Assessment Frequency

Low Risk - Stage 1 every 30 mins, Stage 2 every 15

High Risk - Stage 1 every 15, Stage 2 every 5 mins

FHR Bradycardia

less than 110 bpm for atleast 10 mins
causes: maternal hypotension or hypothermia, cord prolapse, uteroplacental insufficiency

Normal FHR

110-160 bpm

FHR Tachycardia

more than 160bpm for at least 10 mins
causes: maternal fever or infection

Variability

fluctuations in FHR that occur over time, reflecting the interplay between autonomic nervous system and fetal oxygenation
- key indicators of fetal well-being

Absent/Minimal Variability

causes: fetal hypoxemia or acidemia

interventions: lateral position of mom, increase IVF rate, O2 8-10L, report to HCP and document
can also be fetal sleep schedules

FHR Acceleration

• signifies fetal wellbeing, adeuqate fetal oxgenation and neurological integrity

• suggests activeness and responsiveness

• causes: fetal movement, contractions or external stimuli

Decelerations

• can be benign or normal

• three types = early, variable, late

Early Decelerations

• occur early with contraction onset

• mirrors shape/timing of contraction

• shallow/cuplike

• no intervention needed!

• reassuring - vagal stimulation that occurs with fetal head pressure

Variable Decelerations

• occur with or without contraction

• often abrupt onset with U, V or W

• abrupt return to baseline

• non-reassuring

• compression of the umbilical cord

interventions: reposition side to side or knee/chest, end oxytocin, vag exam, oxygen last resort

Late Decelerations

• late with onset of contraction

• shallow and cuplike

• non-reassuring

• result of uteroplacental insufficiency

intervention: side lying, IV + IVF, no oxytocin, elevate legs, O2, prepare for birth

VEAL CHOP

variable - cord compress - reposition
early - head compress - progress
accelerations - okay - none
late - placental insufficiency - intervene

Category I - Normal - No intervention

110-160
moderate variability

present or absent accel
precent or absent early decel
no late or variable decel

Category II - Evaluation and Surveillance

fetal tachycardia or bradycardia
minimal or marked variability

recurrent or late decel with moderate baseline vary
recurrent variable decel with min or mod baseline vary

Category III - Abnormal - Intervene

absent variablity + any of these:
fetal brady
recurrent late decel
recurrent variable decel
sinusoidal pattern (smooth baseline)

Dystocia

abnormal labor progression
complications: hemorrhage, infections, perineal lacerations, anal sphincter injury