OB | ch. 19 and 32 (oxytocin guide only)

what is labor?

the process of moving the fetus, placenta, and membranes out of the uterus and through the birth canal

signs preceding labor?

- lightening or dropping

- bloody show

lightening

- also known as dropping

- the descent of the fetus through the ischial spine

- corresponds with 0 station

what is bloody show?

- pinkish or slightly bloody vaginal discharge that occurs toward the end of pregnancy

- signifies that the cervix is beginning to soften and dilate in preparation for labor

- amount increases with effacement and dilation

- accompanied with release of mucus plug

when is brownish or bloody discharge seen?

- during cervical trauma resulting from vaginal examination

- sex after 48 hours

what are braxton hicks?

irregular painless contractions that occur throughout pregnancy and DO NOT cause cervical dilation

what starts labor?

- fetal hormones (prostaglandins and oxytocin)

- fetal signals (surfactant protein-A)

- fetal movement

- maternal hormones (estrogen and progesterone)

prostaglandins

- released by the placenta and stimulates uterine contractions

- also released during intercourse/ejaculation in sperm

oxytocin

released by the pituitary gland and triggers uterine contractions and cervical dilation

surfactant protein-A (SPA)

- released by the developing fetus and signals the mother's body to prepare for labor

- found in the fetal lungs and picked up by the mom's bloodstream

relationship between fetal movement and labor

increased fetal movement → release of hormones → labor

estrogen

increases throughout pregnancy, preparing the uterus for contractions

progesterone

declines near term, allowing uterine contractions to occur

false vs. true labor

false:

- irregular contractions 

- stops with walking, position change, or comfort measures

- felt in back of abdomen or above umbilicus 

- doesn’t cause cervical dilation 

true:

- regular contractions

- stronger, longer, and closer together

- increases with walking or position changes 

- doesn’t stop with comfort measures 

- felt in lower back radiating to lower abdomen 

leopold maneuvers - purpose, function, and when it occurs?

- a noninvasive way to assess fetal position, presentation, and engagement in the uterus

- detects malpresentation, guides OB management, and streamlines delivery 

- performed in third trimester of pregnancy

what position should the woman be in during leopold maneuvers

- supine w/ pillow under head + knees flexed

- rolled towel under left or right hip (displaces the uterus off major blood vessels)

nursing procedure for leopold maneuvers

- if right handed → stand on right and face woman (and vice versa)

- start at top of uterus ​​→ feel for movement

- feel along both sides of uterus to locate fetal back → use palm to palpate the back and the small parts ie. feet, hands, knees, and elbows 

- feel above pubic bone to identify fetal brow

- identify fetal part that occupies the fundus → head = round, firm, and freely movable, breech = less regular and softer

limitations of leopold maneuver

- not accurate before 38 weeks

- harder to perform in obesity or too much amniotic fluid

frequency of uterine contractions

beginning of one contraction to the next one

intensity of uterine contractions

strength of the peak of contraction

duration of uterine contractions

time between start to end of a contraction

resting tone of uterine contractions

relaxation of the uterus

mild, moderate, and strong palpation of uterine contractions

mild - tense fundus that is easy to indent with the fingertips 

moderate - firm, difficult to indent with the fingertips 

strong - rigid and boardlike, impossible to indent 

what does a vaginal exam determine?

whether woman is in true labor and if membranes have ruptured

when should a vaginal exam be performed?

- on admission

- before med admin

- when contraction frequency and duration changes

- upon maternal request

- urge to push

- ROM or any abnormal fetal heart tracing

precautions for a cervical exam?

- sterile gloves must be used

- # of exams must be limited

spontaneous rupture of membranes (SROM)

- breaking of the "water" or membranes marked by the expulsion of amniotic fluid from the vagina

- woman notices leakage or gush of fluid

artificial rupture of membranes (AROM)

HCP breaks membranes w/ amnihook

what should be documented after the ROM?

- time

- date

- amount

- color (clear, bloody, meconium)

- odor

- FHR before and after ROM (risk for cord prolapse and infection)

nursing interventions upon admission

- welcome woman and family

- educate on admission, procedures, monitoring of status, and progression of labor

- obtain consent

- labs: CBC, rapid HIV, RPR, type and screen (blood type), Rh status, rapid GBS if status is unknown

- notify birth attendant

- obtain ultrasound if needed or unsure of fetal presentation

- prepare for delivery

- assess cultural factors

- supportive care for partner

- collaborate w/ doula

- educate grandparents and siblings

what is a doula?

an experienced female labor attendant that is present during labor and whose primary role is to focus on the woman and provide physical and emotional support

what interventions can a doula provide?

- reassuring words of praise and encouragement, touching, stroking, hugging, comfort measures to reduce pain

- walks with woman, helps change positions, and coaches bearing down efforts

- educates woman about labor progress and advocates for woman

- also supports the partner through encouragement, building relationship, facilitating communication

duration of 1st stage of labor + phases

- onset of regular contractions → complete dilation (10 cm) and effacement of cervix (100%)

phases:

- latent (early): 0 → 5 cm

- active: 6 → 10 cm

interventions for 1st stage of labor

- offer warm showers, hydrotherapy, and to change linens

- clear liquid fluids, NPO w/ ice chips 

- if oral intake of fluids in not permitted → IV fluids w/ LR or D5LR at 125 mL/hr

- encourage ambulation if: membranes are intact, presenting part is engaged, not medicated for pain

- position changes throughout labor

- assess maternal VS every 5-30 minutes and FHR every 5-15 minutes

how does position changes throughout labor benefit the woman?

- increases contraction intensity

- shortens labor

- increases autonomy

- provides distraction

- increases interaction w/ woman, partner, and provider

benefits of walking, standing, and leaning

stimulates contractions and uses gravity to help baby's descent

benefits of kneeling

may relieve back pain, helps baby rotate to OA (best), relieves hemorrhoids

benefits of sitting

uses gravity to help baby's descent, allows rest between contractions

benefits of squatting

uses gravity to help descent and open pelvis for more room

during the first stage of labor, maternal VS should be assessed...

every 5-30 minutes

during the first stage of labor, FHR should be assessed...

every 5-15 minutes

describe contractions in early vs. active phase of labor in 1st stage

early:

- may be irregular

- mild to moderate by palpation

- 2-30 minutes apart

- lasts 30-40 seconds

active:

- 2-3 minutes apart

- lasts 80-90 seconds

describe dilation in nulliparous vs. multiparous women during the active stage of labor in the first stage

- nulliparous - presenting part is usually at 0 station by 6 cm dilation

- multiparous - presenting part is usually at -1 station by 6 cm dilation

describe show in early vs. active phase of labor in 1st stage

early:

- color: brown, mucous plug, or pale pink

- amount: scant

active:

- color: pink to bloody

amount: moderate to

- copious

describe behavior of the woman in early phase of labor in 1st stage

- excited

- thoughts centered on self, labor, and baby

- can walk and talk through contractions

- may be talkative or silent, calm or tense, apprehensive

- pain controlled well

- alert and can follow directions

describe behavior of the woman in active phase of labor in 1st stage

- more serious; doubts ability to continue or control pain

- apprehensive; frustrated; fears loss of control

- desires constant support and encouragement

- attention turned inward; difficulty following directions

- severe pain; backache common

- irritable

- nausea/vomiting (especially with hyperventilation)

- sweating (forehead/upper lip); trembling thighs

- rectal pressure; urge to defecate

duration of 2nd stage of labor

full dilation (10 cm) → birth

what is dilation?

the opening of the cervix (the lower part of the uterus) that connects to the vagina

what is effacement?

the thinning and shortening of the cervix (100% = completely thinned)

describe the latent phase of the second stage of labor

delayed pushing/laboring down/passive descent:

- fetus descends passively through the birth canal and rotates to anterior positions 

- woman is quiet and relaxed

- urge to bear down is not strong w/ some women not experiencing it at all 

- delayed pushing → increases length of second stage but decreased length in pushing time 

describe the active phase of the second stage of labor

- strong urge to bear down 

- ferguson reflex (presenting part of fetus presses on stretch receptors of pelvic floor → oxytocin → more intense contractions)

- woman is more focused, verbal, and urge to bear down grows as presenting part reaches the perineum 

- ring of fire (burning sensation of acute pain as vagina stretches and fetal head crowns)

- women feel powerless and decreased ability to listen/concentrate 

- frequent repositioning and altered respiratory pattern 

- shows excitement when she sees head

signs suggesting onset of 2nd stage

- increase in frequency & intensity of contractions

- urge to push or feeling need to have a bowel movement

- an episode of vomiting

increased bloody show

- uncontrolled shivering

- verbalizations of feeling out of control or unable to cope

- involuntary bearing-down efforts

- continuous 1:1 support (do not leave alone)

- encourage position changes and natural pushing with urge

- promote relaxation, energy conservation, and comfort measures

- avoid closed-glottis/Valsalva pushing (triggers valsalva → increases thoracic and CV pressure → reduced CO and perfusion to uterus and placenta → fetal hypoxia and acidosis)

- coach panting as head crowns; gentle pushing as needed

- maintain hygiene (clean perineum if needed)

- offer emotional support, updates, reassurance

- use mirror or allow touching baby’s head to enhance participation

3rd stage of labor duration

- birth → delivery of placenta

- shortest stage of labor

signs of placental separation during the 3rd stage of labor

- uterus changes from discoid (flattened) → globular (round)

- placenta descends into vagina

- lengthening of the cord

- gush of blood and placental expulsion

what should the nurse assess during the 3rd stage of labor?

- maternal BP, HR, and RR every 15 minutes

- assess for signs of placental separation and bleeding

- APGAR 1 and 5 minutes after birth

- assess maternal and partner response and reactions to birth

interventions during 3rd stage of labor?

- assist with pushing for placental delivery

- administer oxytocin to promote uterine contraction and prevent hemorrhage

- provide comfort, pain relief, and hygiene care (cleanse vulva, fresh linens, ice pack if needed)

- reposition bed and lower legs

- inform parents about placental separation, perineal repair, and medications

- promote bonding: skin-to-skin, delayed cord clamping, delay eye prophylaxis

- encourage breastfeeding within the first hour ("golden hour")

can a child with a genetic/malignant disorder use their own cord blood for treatment? why? where can it be used?

- no, because their blood has the same genetic mutation or early/pre-malignant cells that led to the same disease

- private cord blood banking not generally recommended but can work for family members with genetic disorder or if they benefit from stem cell transplant

duration of 4th stage of labor

delivery of placenta → 2 hours of recovery

diet interventions during 4th stage of labor

- if foods and fluids were restricted → severe hunger

- if no complications → resume regular diet as soon as she likes

- c-section → clear liquids and ice chips

nursing care during 4th stage of labor

- many women wish to breastfeed their baby immediately after birth to take advantage of first period of reactivity (baby's first alert state) and to simulate oxytocin (promotes contractions and prevents hemorrhage)

- usually initiated within first hour and separation from mom is usually discouraged

during the 4th stage of labor, BP and HR should be assessed...

every 15 min for first 2 hours

during the 4th stage of labor, temp should be assessed...

at beginning of recovery, then every 4h for first 8h and then at least every 8h

how to assess the fundus during the 4th stage of labor?

- woman should flex her knees and lay head flat

- press hand firmly into abdomen under umbilicus + stabilize uterus at the symphysis with opposite hand

- if firm + empty bladder + midline uterus → measure fundal height (symphysis pubis → top of fundus)

- if not firm → massage until fundus is firm and clots are expelled

how to assess the bladder during the 4th stage of labor?

- assess distension by noting location and firmness of fundus via observation and palpation

- distended → rounded bulge, dull to percussion, moves like water balloon

- the uterus is usually boggy, above the umbilicus, and moved to the right

how to assess the lochia during the 4th stage of labor?

- observe lochia on perineal pads and linen for amount, color, size, number of cloths, and odor

- observe perineum for sources of bleeding (ie. episiotomy, lacerations)

how to assess the perineum during the 4th stage of labor?

- turn woman to side + flex upper leg on hip

- lift upper buttock

- observe the perineum 

- assess episiotomy or laceration for REEDA (redness, edema, ecchymosis, drainage, and approximation)

- assess for hemorrhoids 

what is the PAR score?

- score to determine post-anesthesia recovery level

- determined on arrival and updated every 15 minutes

- includes activity, respirations, BP, LOC, and color

if woman received epidural or spinal, she should be able to:

- raise her legs

- extend at the knees off the bed

- flex her knees

- place feet flat on bed

- and raise butt off the bed

- numbing/tingling should be gone (time will vary)

nullipara vs. multipara women: early phase (first stage)

nulli:

7-8 hours

contraction every 5 minutes lasting 30-40 secs

multi:

4-5 hrs

nullipara vs. multipara women: active phase (first stage)

nulli:

8-10 hrs

dilation 1.2 cm/hr

contractions every 2-5 minutes lasting 40-60 secs

multi:

6-7 hrs

dilation 1.5 cm/hr

nullipara vs. multipara women: transition phase (first stage)

nulli:

0-30 minutes

strong contractions every 1.5-2 mins lasting 60-90 secs

multi:

0-30 minutes

nullipara vs. multipara women: birth phase

nulli:

50 minutes

79 minutes w/ epidural

contractions every 2-3 mins lasting 40-60 secs

multi:

20 minutes

45 minutes w/ epidural

oxytocin action

- hormone produced in the posterior pituitary gland that stimulates uterine contractions and aids in milk ejection (let-down)

- pitocin is the synthetic form

indications for oyxtocin

- primarily for labor induction and augmentation

- also to control postpartum bleeding

dosage of oxyotcin

- 10 units/1000 mL, 20 units/1000 mL, or 30 units/500 mL

administration of oxytocin

- the IV solution w/ oxytocin should be mixed in a standard concentration

- administered IV route through secondary line connected to the main line at the proximal port (closest to insertion site) 

- always administered by infusion pump 

- begin at 1-2 mu/min → increase by 1-2 mu/min no more frequently than every 30-60 minutes based on woman and fetus’ response and progress of labor 

goal of oxytocin administration

- use lowest dose possible to achieve adequate labor as evidenced by: (1) progressive cervical effacement and (2) dilation of 0.5-1 cm/h after active labor has been achieved

AEs of oxytocin

- maternal: uterine tachysystole, placental abruption, and uterine rupture

- fetal: fetal compromise, decreased in oxygen, neonatal acidemia

considerations for oxytocin

- high-alert medication (significant risk for PT harm when used incorrectly)

- educate PT and pattern on: reasons for use, reactions to expect (intensity of contractions increases more rapidly, holds the peak longer, ends more quickly; contractions come regularly and more often)

- response varies greatly; some PTs only require small amounts while others need larger doses

- uterine response typically takes 3-5 minutes after IV admin

how often should uterine activity and FHR be recorded during the first and second stage?

- record tracing every 15 minutes during first stage and during passive fetal descent

- during active stage of second stage → every 5 minutes

when administering oxytocin, a use a standard definition of uterine tachysystole that does not include...

an abnormal FHR and pattern or the woman's perception of pain

how should oxytocin be titrated?

- titrate the rate of oxytocin to the lowest dose that achieves acceptable labor progress

- dose can be decreased or stopped after ROM and in the active phase of first stage of labor

what to document during oxytocin administration?

- time infusion begin and each time it's increased, decreased, or stopped

- interventions and response for uterine tachysystole, abnormal FHR and pattern

- notification of HCP and their response