NUR 126 Class 10

Identify the premonitory signs of labor.

Warning signs the pregnancy is due during the last few weeks of pregnancy:

Lighting — baby drops down into the pelvis.

Increased Braxton Hicks contractions — practice contractions, irregular, usually not painful.

Increased vaginal discharge from extra blood flow and hormones.

Bloody show — the mucus plug comes out looking pink or brownish.

Rupture of membranes — A big gush or a slow trickle when the water breaks. Check the fetal heart rate to ensure against a prolapsed cord.

Define the following terms:

Amniotomy — Two-layered amniotic sack filled with amniotic fluid to cushion the baby. The provider breaks the sack on purpose using a hook.

Attitude — How the baby’s body parts relate to each other. Normal is flexion with chin, arms, and legs folded into a ball.

Bloody show — The blood tinged mucus from the cervix as it softens and opens. Signals labor is getting close.

Dilatation — How much the cervix dilates from 0-10 cm.

Effacement — Thinning and shortening of the cervix from 0-100%.

Station — How far the baby moves down compared to the spines in mom’s pelvis. 0 means the baby’s head is at the ischial spines. Negative numbers mean above; positive numbers mean below.

Intrapartum — Period during labor and birth.

Leopold’s maneuvers — Four hand positions on mom’s abdomen that palpate where the baby’s head, back, and bottom are.

Lie — How the baby’s spine lines up with mom’s spine. Longitudinal (up/down) is normal; transverse (sideways) cannot be delivered vaginally.

Lighting — Baby lowers into the pelvis before labor.

Nuchal Cord — When the umbilical cord is wrapped around the baby’s neck.

Position — Which way the baby’s presenting part is facing in mom’s pelvis.

Presentation — The part of the baby that comes into the pelvis first. Head (phalic), bottom or feet (breach), or the shoulders.

First Stage of Labor

The longest stage of labor.

Starts when labor contractions start and ends when the cervix is dilated to 10 cm and fully effaced at 100%.

Latent phase — (start of labor to 3-5 cm, hours to days) Pt is social and excited. We want to encourage her to walk and stay hydrated.

Active phase — (4-6 cm, 4-8 hrs) Pt discomfort increases as labor speeds up and will often ask for pain relief.

Transition phase — (7-8 cm, 30 min to 2 hrs) Contractions are very strong with more bloody show. Pt feels urge to push as baby reaches pelvic floor. Pt is serious and inward focused, has leg tremors/nausea and vomiting, feels irritable or helpless.

Second, Third, and Fourth Stages of Labor

Second Stage — Begins when the cervix is completely dilated/effaced and ends when the baby is born.

As the baby moves down and presses on the rectum and pelvic floor, mom gets a strong urge to push that she can’t control. We want to encourage Pt to keep pushing, help her into good positions, and note the time of the birth.

Third Stage — Begins when the baby is born and ends with the delivery of the placenta. As the uterus gets smaller, the placenta separates from the wall. Four signs the placenta is separating: the uterus is round, rises up in the abdomen, the cord gets longer, and there’s a gush of blood. The uterus must stay firmly contracted to stop bleeding vessels and prevent hemorrhaging.

Fourth Stage — Begins with the delivery of the placenta and ends 1-4 hours after birth. Mom is at the highest risk for hemorrhage.

The uterus feels firm and rounded, about 10-15 cm across, or below the belly button. Her bleeding is lochia rubra with a few small clots. Ice packs for the perineum help with swelling and inflammation. Fundus should be at the midline at or below the belly button. Massage if boggy to firm up. A full bladder pushes uterus to the side and can cause bleeding.

Differentiate between the signs of true and false labor.

In true labor…

contractions are regular and get closer together, longer, and stronger with time.

Changes in activity like walking make the contractions stronger and they continue during rest.

Pain starts in the lower back and wraps around to the front. False labor is usually felt in the front in the lower abdomen.

The cervix dilates and effaces. (The only sure sign of true labor)

Assess laboring patients in relationship to the four P’s of childbirth.

Powers — Contractions and Pushing: assess frequency, duration, intensity, and resting tone.

Passage — Pelvis and birth canal: assess size and shape for the baby.

Passenger — Baby and placenta: assess size, presentation, position, attitude, lie, and station.

Psyche — Emotional state: fears, culture, experiences, support system.

Differentiate between normal and abnormal assessment findings during each phase and stage of labor.

Cesarean birth indication:

Fetal Distress — Repeated late decelerations that don’t improve with interventions.

Abnormal fetal position — Breech or transverse lie.

Multiple pregnancies — Especially when the first twin is not head down.

Placental problems — Placenta covering the cervix or coming off the wall too early.

Previous C-section

Maternal health issues — Active genital herpes, severe preeclampsia, certain heart conditions.

Labor complications — labor that stops progression or baby that’s too big for mom’s pelvis.

Cesarean birth procedure overview:

Cesarean birth postoperative care:

Two patients in one (Post-op and postpartum).

Check vitals every 15 minutes.

Palpate the fungus while supporting the incision with your other hand.

Assess for REEDA: redness, edema, bruising, drainage, and approximation.

Track urine output

Walk early

Compression devices on legs to prevent clotting.

Given a description of assessment findings, identify the most significant patient problems and associated nursing diagnoses for the intrapartal patient.

Pain — Acute Pain

Bleeding — Risk for Bleeding

Infection — Risk for Infection

Limited mobility —Impaired Physical Mobility

Blood clots

Urine retention

Hypoactive bowels

Anxiety

Disappointment

Identify key evaluative criteria used to determine progression of labor.

Differentiate the role of the nurse, certified nurse midwife, anesthesiologist, and physician in care of the laboring patient.

Nurse — Assess mom and baby, read monitor, comfort measures, administer meds, teach and advocate.

Certified nurse midwife — An APRN who manages low-risk pregnancies and births.

Anesthesiologist — Provides epidurals and anesthesia for cesarean births.

Physician — Manages high-risk pregnancies, complications, forceps or vacuum births, and cesarean births.

Select appropriate nursing care for the laboring patient during each phase and stage of labor.

Explain how the nutritional needs of the laboring patient are met during the labor and delivery process.

Clear liquids are allowed.

IV fluids typically used.

Solid foods are limited because anesthesia for an emergency caesarean section could cause aspiration of food into lungs.

Postpartum:

Protein, fiber, extra calories, and fluids encouraged.

Determine the effect that developmental level has on patient outcomes during labor and delivery.

Given a situation, identify the most appropriate therapeutic communication technique to use with a laboring patient and her family.

Active listening

Open-ended questions

Provide information

Reflection: repeating what the patient said.

Offering reassurance

Empathy

Silence when tense.

Touch

Provide support to family members

Clarification

Provide choices

Validation

Provide calm presence

Use guided imagery/relaxation techniques.

Identify cultural variations and beliefs associated with the labor and delivery process.

Using Seyle’s model of stress adaption, determine the stage of adaption the patient is in related to LAS, GAS, and PGAS.

Compare and contrast the use of external and internal fetal monitoring to monitor fetal oxygenation.

Fetal monitoring assesses whether or not the baby is getting enough oxygen during labor. Every time the uterus contracts, it briefly reduces blood flow to the placenta.

Fetal heart rate is at the top of the strip and the contractions are on the bottom.

External fetal monitoring — Belts are placed on the outside of the mom’s abdomen. It can tell us how often and how long the contractions are, but not how strong they are. Noninvasive but can slip when the mother moves.

Internal fetal monitoring — A device is placed inside the uterus and onto the baby’s scalp. Provides the most accurate heart rate, strength of contractions. Invasive with infection risk because the membranes have to be ruptured, the cervix must be dilated a few cm, and the presenting part must be reachable.

Oxygenation monitoring — Judged mostly by the infant heart rate pattern. FHR variability is the irregular amplitude fluctuations of the fetal heart rate. Absent variability has undetectable amplitude like a flat line. Minimal variability has FHR fluctuations between 1-5 bpm and shouldn’t last long. Moderate variability has FHR fluctuations between 6-25 bpm and is optimal. Marked variability has FHR fluctuations over 25 bpm and needs to be watched.

Given a specific situation, assess the oxygen transport status of the fetus in regard to baseline fetal heart rate, accelerations, and decelerations.

Reassuring Patterns — Baseline FHR 110-160, moderate variability, and accelerations.

Non-Reassuring Patterns — Abnormal FHR baseline, absent or minimal variability, late or variable decelerations.

L.I.O.N. Interventions: Lie on the left side to take pressure off the cord. Administer oxygen and increase IV fluids. Discontinue meds causing uterine contraction (oxytocin). L&D nurse performs a vaginal examination. Notify the provider. Prepare for possible C-section if no improvement.

Categories: 1. Normal, 2. Between, 3. Abnormal

Determine the most appropriate nursing intervention for a fetal patient given the fetal heart rate, acceleration, and deceleration pattern.

If there are variable decelerations in fetal heart rate from baseline that don’t line up with contractions, reposition the mom to take pressure off the cord.

If there are “early” decelerations in FHR, they mirror the mom’s contractions and are normal. The baby’s head is compressed, stimulating the vagus nerve to slow the heart rate.

If there are accelerations in FHR from baseline, this is reassuring.

If there are late decelerations in FHR, there is a gradual dip that occurs after the peak of contraction and doesn’t return to baseline until after the contraction ends. Requires action right away because the baby is not getting enough oxygen from the placenta.

Describe nursing interventions to teach the laboring patient and her family during intrapartum.

Identify legal/ethical standards of nursing related to care of the laboring patient.

The legal/ethical standards of nursing care are doing what a reasonable prudent nurse would do in the same situation.

Informed consent must be obtained by the physician. The nurse must witness the signature and ensure the patient understands the procedure.

Identify risk factors and assessment findings that support the nursing diagnosis of risk for infection and/or risk for impaired urinary elimination for patients during intrapartum.

Identify the purposes for bathing patients.

Name three abnormalities you might encounter during perineal care.

Explain cultural values and variables that influence skin care and hygiene.

Explain how you can minimize patient personal anxiety during perineal care.

Describe the procedure for perineal care, include the uncircumcised male.

Describe five risk factors for oral problems.

Assess the labor and delivery patient for pain through each phase and stage of labor.

First stage of labor: early labor, active labor, and transition phase.

Pain comes mostly from the cervix dilating and thinning, and the uterus contracting. Cramping in lower abdominal area and back.

Second stage of labor: from full dilation to delivery.

Pain comes from the baby stretching the vaginal area and perineum. Intense pressure and the urge to push. A burning, stretching feeling as the head crowns.

Third stage of labor: delivery of the placenta.

Some discomfort from contractions and the cervix stretching, as the placenta passes through, but it’s usually short and mom is focused on the baby.

Fourth stage of labor: recovery period.

Afterpains include the uterus retracting back down and from any tears or episiotomy repairs. Massaging the fundus and breastfeeding makes pain worse.

Select the most appropriate nursing intervention for care of the laboring patient in pain given a specific situation.

Nonpharmacologic pain management:

Breathing techniques — slow deep breathing aids in relaxation early in labor.

Relaxation — lightly massage the abdomen and apply firm counter pressure on the lower back.

Positioning — walking, staying upright, and using a gravity ball helps the baby descend. Change position every 30 minutes. Don’t lie flat on the back because the weight of the uterus reduces blood flow to the uterus.

Medications:

Analgesics — Opioids given IV or IM. (takes the edge off)

Anesthesia — Put to sleep for C-sections.

Regional anesthesia — Numbs one region of the body. (Epidural, spinal, pudendum block)

Identify common drugs used for pain during labor and delivery and their side effects.

Opioids — (fentanyl, Morphine) drowsiness, nausea, a drop in blood pressure and slow breathing. Opioids cross the placenta and may cause trouble breathing in the baby after birth. Fall precautions.

Naloxone and Narcan reverse opioids.

Epidural analgesia — hypotension, urinary retention, itching, low fever, pushing might be lengthened. Fall precautions. If blood pressure drops, turn patient on to side, increase fluids, and notify the provider.

Nitrous oxide — A gas that is half nitrous oxide and half oxygen that mom breathes through a mask. Fast onset and short duration. Have mom hold the mask so that if she gets drowsy, the mask will fall.

Local anaesthesia — injected into the perineum to numb it for episiotomy or a tear repair. Few side effects. A metallic taste or numb lips can be an early sign of a reaction.

Describe cultural variation in health beliefs and practices related to the experience of pain during labor.

Different cultures have different expectations around pain expression and management.

For some cultures, pain has special meaning and impacts how they perceive it.

To provide culturally sensitive care, ask about preferences.

Discuss the effect developmental level has on the ability of the patient to cope with pain.

Adolescents may experience heightened anxiety and require additional support and education.

They need clear explanations of what to expect and what you’re going to do.

Differentiate the role of the nurse, certified nurse, midwife, anesthesiologist, and physician in providing care to a laboring patient in pain.

Nurse — Continuous assessment, support, and intervention.

Certified nurse midwife — Comprehensive prenatal care and delivery support.

Anesthesiologist — Administration of anesthesia and monitoring.

Physician — Overseeing overall labor and delivery management.

Identify legal/ethical standards of nursing related to care of the laboring patient in pain.

Informed consent and patient autonomy.

Documentation and legal responsibilities.

Ethical considerations in pain management and patient care.

Determine the affect stress adaption has on the patient’s response to pain and pain management interventions.

Fear causes tension, tension causes pain, pain causes more fear.

Stress triggers fight-or-flight response. Stress hormones like adrenaline are released, which slow contractions, reduce blood flow to placenta, and make the pain feel worse.

We can break the cycle by explaining what’s happening, What’s coming next, giving choices, facilitating continuous support.