Labor, Fetal Monitoring, OB exam 1

5 P’s of Labor

Power

Passageway

Passenger

Pyshce

Position

Power

uterine contractions + pushing

Primary Powers

involuntary uterine contractions

Cause of primary powers

• cervical dilation

• cervical effacement

Where do contractions occur?

upper 2/3 of the uterus/fundus

How do we assess contractions?

frequency, duration, and intensity

Frequency

beginning of one contraction to beginning of the next

Duration

beginning to end of contraction

Intensity

strength of contraction

Secondary powers

voluntary pushing efforts

When does secondary powers start?

during second stage of labor

Pelvic Shapes

• Android

• Anthropoid

• Gynecoid - best

• Platypelloid

Passageway

maternal pelvis + soft tissues

Factors affecting passageway

• shape of the pelvis

• Ability of soft tissue to stretch

• Pelvic floor muscles

• Maternal positioning

Fetal station

Describes the relationship btw the presenting fetal part and the maternal pelvis

What is the range for fetal positioning?

-5 to +5

Negative numbers

presenting part is higher/farther from birth

0 Station

levels of the ischial spines

positive numbers

fetus is descending toward birth

+5

crowning

Dilation

opening of cervix

measured 0-10 cm

10 cm = completely dilated

Effacement

cervix becomes shorter/thinner

Crowning

fetal head begins to emerge from the vaginal opening

Passenger

fetus

Fetal head

• largest part of the fetus

• least malleable part

Molding

• fetal skull sutures and fontanels shift to allow the head to change shape which passing through the birth canal

• Can produce cone head appearance

Presentation

The part of the fetus that enters the maternal pelvis first.

• Cephalic = head

• Breech = buttocks/feet

• Shoulder

Fetal Lie

• Longitudinal = vertical (cephalic or breech)

• Transverse = horizontal (shoulder)

Fetal Position 1st letter

• Maternal side

  • L = left

  • R = Right

Fetal Postion 2nd Letter

• presenting part

  • O = occiput

  • M = Mentum

  • Sc = Scapula

  • S = Sacrum

Fetal Position 3rd Letter

• A = Anterior

• P = Posterior

• T = Transverse

Psyche

mother’s emotional state and feelings

Factors to Mom’s Psyche

• fear

• anxiety

• stress

• feelings about pregnancy/labor

• Perception of pain

Psych L&D Nursing Role

• advocate for the mom and baby

• meet the patient where she is emotionally

• provide support

• help decrease fear and anxiety

Position

maternal position can affect labor

Positions can

• use gravity

• help provide the widest diameter of the pelvis

• affect the passageway

Signs of Labor Include

• Regular contractions

• Bloody show

• Descent of fetus in pelvis

• Nesting

• GI upset

• weight loss SROM

• Cervical change

Nursing Care During Labor

• Start an IV commonly 18 gauge

• Draw blood

• collect urine

• monitor vs

• provide fetal monitoring

• Encourage the woman to void at least every 2 hours

• assess labor support

• provide education

• administer pain medications as ordered

Pain principle

• pain is what the patient says it is

• multifactorial

First Stage of Labor Pain

• abdomen

• low back

• thighs

Pain occurs when

contractions are present

Continuous pain can mean

back labor or placental abruption

Second Stage of Labor Pain

• Burning

• Pressure/sensation in the perineum

Opioid for pain

• IV or IM

• Used for labor pain

Neuraxial analgesia/anesthesia

• epidural

• spinal

Pudenal Block

Local anesthesia injected near the pudendal nerve

Nitrous Oxide S/E

• Nausea

• Vomiting

• Lightheadedness

Epidural/Spinal Considerations

• Pt curls over the baby to help open the vertabrae

• Obtain a baseline blood pressure

• If medication affects one side more = reposition/roll to ineffective side

• Naloxone should be available

• Potential risk of spinal headache

  • Caffeine may

  • Family is welcome for spinal

• General anesthesia = no family members

Nitrous oxide use

• pt remains more alert

• can still feel pain

Non-pharm pain management

• movement

• hypnosis

• counterpressure

• effleurage

• touch/massage

• aromatherapy

• guided imagery music

Counterpressure

helpful for back contractions

Effleurage

slow/light movements used as a distraction technique

Guided imagery

patient closes eyes while the nurse/support person describes a relaxing place in detail

Touch/massage

can help release endorphins

First stage of labor

beginning of true labor - complete cervical dilation

latent phase

0-3cm

• longest phase

• contractions begin/are developing

Active phase

3-7cm

• Contractions begin

  • more regular

  • more painful

Transition phase

8-10 cm

• shortest phase

• most intense

• strong contractions

• contractions become closer

First Stage of Labor Nursing Care

• Obtain IV access

• Draw blood

• collect urine

• administer medications as indicated

• provide pain management

• monitor maternal VS

• monitor FHR

• Encourage frequent voiding

• Promote ambulation

• Cluster care

• minimize unnecessary vaginal exams

• provide psychosocial support facilitate cultural beliefs/practices

• prepare room for delivery

Second Stage of Labor

10 cm = second stage begins

Pushing may be delay …

until the women feels the urge to push

2nd Stage duration

20 min - 2+ hours

2nd Stage of Labor include what movements

cardinal movements of labor

2nd Stage Nursing Care

• Fetal monitoring

  • Continuous or periodic

  • Every 5-15 min or after every contraction

• Maternal VS hourly

• Assist w/ positioning

• support and encourage positioning

Postion

• avoid staying in one position too long

• No more than 15 min per position

Third Stage of Labor

Birth of infant - delivery of placenta

What happens during the 3rd stage of labor?

• uterus contracts

• placenta separates and is delivered

• Uterine contraction continue after placental delivery

Why are contractions important?

they help “pinch” closed the blood vessels in the uterus and prevent hemorrhage

Uterine atony

primary cause of postpartum hemorrhage

3rd Stage of Labor Nursing Care

• Maternal VS every 15 mins

• assist with fundal massage

• assist with delivery of placenta

• assist with newborn evaluation

• APGAR scoring

• Two nurse may be involved

• NICU/pediatirc team may be involved

4th Stage of Labor - Placenta

Birth of placenta - firt 4 hours postpartum or until mother is clinically stable

4th Stage of Labor Assessment and Care

Assess

• Uterine position

• Vaginal bleeding/lochia

• VS

Care

• pain medication PRN

• Assist with ambulation

• Encouragefrequent voiding

• Skin to Skin

• Initiate breastfeeding

Purpose of Fetal Monitoring

Fetal monitoring assesses the fetal heart rate (FHR) for patters that may indicate fetal compromise and the goal is to maintain adequate oxygenation

Contraction Description

• Mild - cheek

• Moderate - nose

• Strong - forehead

Increment

contractions begin/intensifies

Acme

peak

Decrement

contraction decreases

Stress, anxiety, and fear can effect

• Decrease pain tolerance

• Make coping more difficult

• Potentially interfere with labor progress

Helpful concepts for positioning

• upright positions can use gravity

• position changes can shift pelvic

• squatting, side lying, hands and knees, standing, and ambulation may be useful depending on the patient and clinical perfusion

Flat position with legs elevated can effect

• Narrow the pelvic passageway

• contribute to supine hypotension

• Decrease maternal/uteroplacental perfusion

Signs of Labor

• Braxton Hicks Contractions

• Increased vaginal discharge

• Cervical changes

• Nesting/energy surge

• GI symptoms

• Approximately 1-3 lb weight loss

True Labor Signs

• Contractions become regular

• Contractions progress in strength/frequency

• Cervical dilation occurs

• Cervical effacement

SROM

Spontaneous rupture membranes

When membranes rupture, assess;

• Color

• Amount

• Odor

• Timing

SROM Concerning Finds

• Meconium

• Cloudy/fould smelling fluid

• Abnormal color/odor

Remifentanil - Opioid

• PCA

• Very short acting

• Rapid metabolism

• Maternal/fetal respiratory depression is a major concern

Remifentanil =

rapid on/off + respiratory depression

Meperidine (Opioid)

• IM/IV

• Single dose lasts approximately 3-4 hrs

• Neonatal respiratory depression is most concerning if birth occurs within 4 hours after administration

Fentanyl MOA

• IV/IM/PCA

• Rapid onset

• Short duration

• Crosses placenta

Fentanyl S/E

• Maternal respiratory depression

• Neonatal CNS/respiratory depression

• N/V

• Pruritus

• FHR monitoring

Mixed Opioids Agonist/Antagonists Ex:

• Nalbuphine (Nubain)

• Butorphanol (Stadol)

• Pentazocine (Talwin)

Mixed Opioid Agonist/Antagonists Advantages

• Less respiratory depression than full opioid agonists

• May cause less nausea/vomiting

Antiemetics - Promethazine

• Often used with opioids

• Monitor for hypotension

Antiemetics - Hydrixyzine

• Often used with opioids

• IM only

• No IV administration

Neuraxial Analgesia/Anesthesia

• Epidural

• Spinal/intrathecal

• Combined spinal-epidural (CSE)

Epidural

Can provide:

• Analgesia

• Anesthesia

Can be used for:

• Vaginal birth

• Cesarean birth

Spinal/Intrathecal

Subarachnoid space containing CSF

Spinal:

• Rapid onset

• Often used for surgical anesthesia

• Provides dense anesthesia

CSE

Combined spinal-epidural Advantages

• Faster onset than epidural

• Can provide both rapid spinal medication and ongoing epidural dosing

• Onset approximately 3–5 minutes faster than epidural

• Pain relief/birth outcomes are comparable

• More pruritus and fetal bradycardia may occur with CSE

Childbirth Education

• Confidence building

• Coping techniques

• Distraction

• Breathing techniques

Breathing Techniques

• Provide distraction

• Increase sense of control

• Promote relaxation

• Optimize oxygenation