childbirth

Reproductive sign to labor

- Uterine contractions: g Normal labour contractions are coordinated, involuntary, & intermitent g

During labour, contractions assume a regular pattern of increasing frequency, duration & intensity -

Cervical changes: o Effacement g Dilatio

Other sign preceding to labor

Contractions decrease blood flow to placenta

Supine Hypotensio

Hyperventilation

Blood

Fetal response to labor

Placental Circulation: During labor contractions, blood flow to placenta decreases -

Cardiovascular System: Fetal heart rate reacts quickly to labor events FHR=110-160 bpm at term -

Pulmonary System: Fetal lungs are filed with fluid to allow airways to develop This fluid is expelled during passage through birth canal

Component of birthing process

2 POWERS: Uterine contractions (Primary) -

Maternal pushing efforts (Secondary)

2 PASSAGE; Maternal pelvis Soft tissue

POSTION; Frequent position changes

Upright position

PASSENGER: - Fetal head -

Fetal Lie: the orientation of the long axis of the fetus to the long axis of the woman

, Attitude: the relation of fetal body parts to eaoch other - Presentation: the fetal part entering the pelvis first is the presenting part. Three types: cephalic, breech, and shoulder

PSYCHE: - A crucial part of childbirth - Marked anxiety, fear or fatigue decreases a woman's ability to cope with pain in labor - Maternal catecholamines secreted in response to anxiety or fear can inhibit uterine contractility and placental blood flow.

Sign preceding labor

8 Braxton Hicks Contractions; -

lrregular, mild uterine contractions that occur throughout pregnancy -Become stronger in the last trimester

Lightening; Descent of the fetus into the pelvis before labor

Bloody Show: Mixture of cervical mucus and blood "mucous plug"is expeled into vagina

Energy spurt "nesting 0 Softening "ripening' of cervi

Cervix becomes soft, partially effaced & may begin to dilate

Small weight loss

The changing levels of estrogen & progesterone produce electrolyte shifts.

This causes excretion of extra fluid accumulated during pregnancy gPossible rupture of membranes 日Backache 0 Return of urinary frequency

True labor

Contractions; At regular intervals: intervals between contractions gradually shorten 0 contractions increase in duratio

O contractions increase in intensity

Walking tends to increase egins in the lower back and radiates to lower abdomen

Back pain may persist

Early labor feels like menstrual cramps

Progressive dilation & effacement of the cervixX

False labor

Contractions; 口Are irregular with an inconsistent pattern

No change in intensity, frequency, duration

Change in activity (has no effect or may even lessen contractions

Contractions; 口Are irregular with an inconsistent pattern

No change in intensity, frequency, duration

Change in activity (has no effect or may even lessen contractions

More annoying than painful 2 Can subside with comfort measures

No change in effacement on dilation of the cervix

First stage latent phase

Latent phase; - Beginning of labor to 3 cm dilated -( Cervical effacement occurring -

Woman is usually sociable and excited Contractions:

F: q 5-30 min.

I : mild to moderate

D: 30-45 sec.

Patent phase nursing care

Establish trust/therapeutic relationship

Nursing History

Assess mother's labor status, vital signs

Fetal assessments

Comfort level

Maternal assessment during latent phase

MATERNALASSESSMENTS

Vital Signs

Contractions

Presenting part & fetal position

Progress of Labor - Cervical dilation & effacement -

Fetal descent (station

Latent phase fetal assessment

FETALASSESSMENTS

FHR (fetal heart rate)

Amniotic fluid -Colour - Odour -Amount -Time of membrane rupture (SROM, AROM)

Active phase first stage

Active phase -

Cervix 4-10cm - Cervical effacement complete -

Bloody show often increases with full cervical dilation

- Woman becomes more anxious and may feel anxious as the contractions intensify -

Very strong contractions; urge to push; Woman may be irritable & lose control - Contractions:

F: q2-5 min.

l: moderate - very strong

D: 40-90 sec. (>90→ report)

First stage active phase nursing care

Assist with comfort measures (pain, nausea & vomiting

) Assist with breathing

Side-lying position to promote placental functioning

Encourage voiding

Caring presence - support birth partner

Assess for fetal compromise

Assist with analgesia as required

Station

describes the descent of the fetal presenting part in relation to the level of the maternal ischial spines.

The level of the ischial spines is a zero station.

described with numbers of cm above (negative numbers) or below (positive numbers) the ischial spines.

团As the fetus descends through the pelvis, the station changes from negative to positive numbers.

Oxytocin action

Stimulates uterine smooth muscle

Aids in the milk let-down reflex (breastfeeding,

Oxytocin indication

Labor induction and augmentation

Facilitate placental detachment

Controls postpartum bleeding

Oxytocin se

Hypertonic uterine activity

placental abruption

uterine rupture

lmpaired uterine blood flow

abnormal FHR

fetal hypoxemia

Maternal and/or fetal trauma (d

Comfort measure

lmprove woman's ability to relax and use coping skills:

Lighting

Temperature

Cleanliness

Mouth care

Positioning Bladder

Second stage

Assist with pushing

Monitor fetal and maternal status

Support birth partner

Provide comfort measures

Ends with birth of baby

Ineffective response in labor

Fetal Heart Rate outside the normal range of FHR= 110-160 bpm for a term fetus

gMeconium-stained (greenish) amniotic fluid

Cloudy, yellowish or foul odor amniotic fluid (suggests infection) 0 Excessive frequency or duration of contractions,>90 sec 0

Maternal hypo or hypertension Maternal fever - 38 C or higher lncomplete uterine relaxation (<30 sec. between contractions) Persistent bright-red vaginal bleeding

0 Absence of fetal movement

4 stage assessment first 2hr

VIS & SKIN COLOUR

FUNDUS (firm)

LOCHIA (rubra)

PAIN (afterpains & perineal)

IV infusions

VOIDING

CHILLS 2

Feeling and ability to move post- epidural

4 th stage intervention

VIS qhour

Massage relaxed uterus

Assess for heavy lochia (PPH lce packs on perineum decrease discomfort and swelling

Oral analgesia (ie: ibuprofen, tylenol

Monitor IV

Assess for full bladder

Providing warmth (ie: blank

Pph

Early postpartum hemorrhage: hemorrhage in the first 24 hours after childbirth.

2 Late postpartum hemorrhage: hemorrhage after 24 hours up to 12 weeks after childbirth.

Pph cause

trauma to the birth canal during labor & delivery

hematomas (localized collections of blood in a space or tissue) retention of placental fragments

abnormalities of coagulation

Uterine atony

Predisposing Factors for Postpartum Hemorrhage

Overdistention of the uterus (multiple gestation, large infant) Multiparity

Precipitous labor or delivery

Prolonged labor

Use of forceps or vacuum extractor

0 Cesarean Birth

Manual removal of placenta

Clotting disorders 0

Previous PPH or uterine surgery

Presence of fibroids (leiom

Early PPH

Occurs during the first hour after delivery.

团Most often caused by uterine atony.

0 Uterine Atony: lack of muscle tone in the uterus resulting in failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates.

Pph ss

Uterus not contracting or does not remain contracted

Uterine fundus difficult to locate.

日A soft or "boggy" feel when the fundus is located.

0 A uterus that becomes firm as it is massaged but loses its tone when massage is stopped.

0 Large gush or slow, steady trickle or ooze of blood from the vagina.

0 Saturation of 1 peripad per 15 minutes

Excessive clots expelled; excessive lochia especialy if it is bright red.

Severe, unrelieved perineal or rectal pain a

Tachycardia, low BP

Pph care

Fundal massage

Monitor V/S & LOC q15 minutes 0

Catheterization of full bladder

0 Monitor urine output

lntravenous therapy; Ensure IV access N/S bolus or R/L (Ringer's Lactate) to replenish blood volume lost from excessive bleeding IV Syntocinon/Oxytocin

Monitor lochia, presence of clots Documentation of sequence of events

PPH tx

Manual removal of placenta

Pharmacologic measures: Oxytocin/Syntocinon: 个 uterine tone & controls bleeding.

Given via IV infusion.

Cytotec: given rectally to control bleeding.

Prostaglandins: given lM to stimulate uterine contraction.

Blood transfusions 0 D &C (dilation & curettage)

Hysterectomy (last resort to save the woman's life if hemorrhage is uncontrollable).

PPH indication

lndications: 0 Dystocia

Cephalopelvic disproportion (CPD)

Fetal malpresentations (ie: breech, shoulder

Prolapsed umbilical cord

abruptio placenta or placenta previa a

Maternal diseases ie: hypertension, diabetes, heart disease, cervical cancer Active genital herpes at the time of birth

Cs pain management

团Following the C/S birth, most women will receive morphine through the catheter for 24 hour pain relief.

团Facilitates early ambulation.

团NSAIDs may also be prescribed during the first 24 hours for breakthrough pain.

日NARCAN: opioid antagon

Regional anesthesia

Used for analgesia and anesthesia -

Provides pain relief without loss of consciousness - Women can participate in birth yet still have good pain control - Epidural block, spinal block - lnformed consen

Epidural

EPIDURAL BLOCK

Provides pain control during much of the labor and for the birth itself 日Useful for both vaginal & C/S birth

A local anesthetic is injected into the epidural space (L3-L4) of the spinal cord via a catheter inserted through a needle

The catheter allows continuous infusion or intermitent injection of the anesthetic

Epidural se

0 Adverse effects of epidural anesthesia: ie: lidocaine/xylocaine, bupivacaine -Maternal hypotension -Bladder distention - Prolonged Second Stage - Fever

e: fentanyl, morphine (C/S) -Respiratory depression/sedation -Nausea & vomiting -Pruritis: itching of the face & neck

Spinal block

when a quick cesaean birth is necessary and an epidural catheter is not in place.

Local anesthetic is injected into the subarachnoid space in a single dose.

Woman loses both sensory & motor function below level of the spinal block.

0 Adverse effects: matenal hypotension, bladder distention, and spinal headache (postural

Nitrous oxide

Nitrous oxide mixed with oxygen can be inhaled via a face mask or mouthpiece to reduce pain in 1st & 2nd stage of labor.

Maximum effect of action: 50 seconds. Used intermitently during contractions.

Does not depress uterine contractions or cause adverse effects to the fetus/newborn.

Adverse effects: nausea & vomiting, drowsiness, dizziness, hazy memory, loss of consciousnes

Pudendal Block

Anesthetizes the lower vagina and part of the perineum.

01 Provides anesthesia for an episiotomy and vaginal birth, using low forceps if needed