NURS 333 Module 2 Labor and Delivery

hospitals

- Over 98% of deliveries occur in hospitals (2012)

- Provides access to key personnel, equipment, pain control options, and emergency services

home births

- 88% of home births are intentional; 12% precipitous

- Many choose home births because of negative hospital experiences

- Women may feel more comfortable, empowered, and in control at home

birthing centers

- Generally freestanding centers are not located in a hospital.

- Midwives attend most births in birthing centers.

- Cater to women with low-risk pregnancies.

- Transfer agreements with local hospitals.

Involuntary uterine contractions

Occur in upper 2/3 of uterus

Apply pressure to fetus → pressure to amniotic fluid, lower portion of uterus & cervix → cervix dilated and effaced → allows for passage of fetus, amniotic fluid, membranes, placenta

Ferguson reflex

reflex contractions (urge to push) of the uterus after stimulation of the cervix when the presenting part of the fetus reaches the perineal floor

voluntary contraction

Muscle contraction under conscious control.

dilation

how open they are

0-10 cm

effaced

0-100%

10 cm

When should secondary powers (i.e., voluntary pushing) start?

The muscles of the pelvic floor

help turn and orient the fetus

fetal station

The relationship between the fetal presenting part and the pelvis is assessed by

zero station

The level of the ischial spines is referred to as

the presenting part has reached zero station

Fetus is engaged when?

station

-5 to +5

fetal head size

Typically the largest part of fetus

Unfused skull bones allow for head to change in reference to birth canal

fetal presentation

The part of the fetus that enters the pelvis 1st (presenting part)

Majority of fetuses enter pelvis head first - AKA cephalic presentation

Other presentations: breech (buttocks or feet) & shoulder

fetal attitude

Position of fetal body parts in relationship to one another (flexion/extension)

Typical attitude = flexed neck, arms, legs & rounded back - optimal!

fetal lie

Relationship of the long axis of the fetus to the long axis of the mother

Longitudinal or transverse (rare: oblique)

Passenger: Fetal Position

Described w/ a series of 3 letters

1st letter = Right (R) or Left (L) - Refers to MATERNAL R or L

2nd letter = Presenting part (fetal)

Occipital bone (O): vertex presentation

Chin (mentum [M]): brow/face presentation

Buttocks (sacrum [S]): breech presentation

Scapula (acromion process [A]): shoulder presentation

3rd letter = position of the presenting part as

Posterior (P)

Anterior (A)

Transverse (T)

Examples:

Left Occiput Anterior (LOA)

Occiput Posterior (OP)

ROP

LOP

ROA

LOA

psyche

A woman's psyche can impact labor

Examples of factors that can delay labor progress:

Anxiety

Stress

Fear

Pain tolerance

Relaxation can augment labor

Childbirth education

Trust in support people & care providers

Doula support

Signs of Labor

Contractions become regular (q 4 min x 1 min for 1 hr //411)

Presence of bloody show

Descent of the fetus into the birth canal (lightening), may occur about two weeks before labor for a primigravida

Nesting impulse

GI distress (heartburn, nausea, diarrhea)

Weight loss of 1 to 3 pounds just before onset of labor

bloody show

first stage of labor

regular contractions that cause progressive dilation and effacement of the cervix (longest stage - divided into 3 phases)

Latent phase: 0-5 cm dilation

Active phase: 6 cm - 10 cm dilation

second stage of labor

starts with complete dilation of cervix, pushing, and ends with the birth of the baby

third stage of labor

begins just after the birth of the baby and ends with delivery of the placenta

fourth stage of labor

begins just after the delivery of the placenta and ends after 4 hours or when the mother becomes clinically stable

Latent phase characteristics (0-5 cm)

Longest lasting phase of labor

Period of excitement for some, anxiety for others

Contractions feel like menstrual cramps (or lower back ache) and are mild to palpation (nose)

Active phase characteristics (6-10 cm)

Women may become more focused, anxious, or restless

Contractions become more regular and painful

Contractions are moderately strong to palpation (chin)

Contractions strong and close together (forehead)

Women may feel out of control, irritable, exhausted, or dependent

May experience N&V, bloody vaginal discharge typical

D. Vaginal examination

A woman states that she thinks she is in labor as she enters the perinatal triage unit. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status?

A. Leopold maneuvers

B. Frequency of uterine contractions

C. Fetal heart rate assessment

D. Vaginal examination

A. Check the patient's cervix to determine if the patient is in the transition phase of labor

A patient's cervix was 5 cm dilated and 80% effaced 2 hours ago. She is now agitated, irritable, and her contractions have increased in intensity. What should the nurse do next?

A. Check the patient's cervix to determine if the patient is in the transition phase of labor.

B. Discuss pain medication options.

C. Notify the provider of the patient's change in condition.

D. Prepare for the second stage of labor.

labor pain

Pain is what the patient says it is!

Many factors play a role in pain tolerance, including:

Fear

Previous experiences with labor pain

Support system

Fatigue

Manifestations of pain include:

Pain in abdomen, low back, or thighs with contraction

Continuous pain in low back may occur if fetus is in an occiput-posterior position

Continuous abdominal pain may indicate a placental abruption

Opioids for labor pain

Fentanyl—short acting (1-2 hours), may cause maternal or neonatal respiratory depression

Mixed opioid agonist/antagonists for labor pain

Nubain (nalbuphine)—single dose lasts 3 to 6 hours

Stadol (butorphanol)—single dose lasts 3 to 4 hours

Should not be used in women who are dependent on opioids because may cause withdrawal

Less risk of respiratory depression than opioids

Nitrous oxide for labor pain

Self-administered analgesic gas that the patient inhales for 15-30 seconds before the start of each contraction.

Side effects include nausea, vomiting, vertigo and lightheadedness

Epidural Analgesia/Anesthesia

involves injection of local anesthetic and an opioid analgesic into the lumbar epidural space

61% of women receive an epidural in the U.S.

Given continuously throughout labor

Can be used for vaginal deliveries or C-sections

Can potentially increase the duration of 2nd stage of labor

Epidural Analgesia/Anesthesia side effects

Nausea and vomiting

Hypotension *

Fever

Pruritus

Intravascular injection

Maternal fever

Allergic reaction

Respiratory depression

Infuse 1,000 mL of lactated Ringer's IV fluid

Have the woman empty her bladder

Which of the following actions would the nurse expect to perform immediately before a woman receives epidural anesthesia? Select all that apply.

Assess fetal heart rate

Infuse 1,000 mL of lactated Ringer's IV fluid

Place the woman in the Trendelenburg position

Monitor blood pressure every 5 minutes for 15 minutes

Have the woman empty her bladder

true

Is the following statement true or false?

Nonpharmacologic pain management techniques should only be used during the latent phase of labor.

Drop in blood pressure

Immediately following epidural anesthesia administration, the nurse must closely monitor the mother for which of the following side effects?

Numbness and tingling in her legs and feet

Drop in blood pressure

Increase in central venous pressure

Fetal heart accelerations

fetal monitoring

Assessment of the fetal heart rate (FHR) for patterns that may indicate fetal compromise

A normal (or reassuring) pattern is associated with positive outcomes for the neonate.

Abnormal (or nonreassuring) patterns are associated with hypoxemia and may lead to fetal hypoxia → metabolic acidosis

When describing FHR pattern, 5 components are assessed:

Baseline FHR

Variability

Accelerations

Decelerations

Uterine contractions

Uterine Contractions

Assessment of uterine contractions looks at the number of contractions during a 10-minute window, averaged over 30 minutes.

NORMAL: ≤ 5 contractions in 10 minutes

TACHYSYSTOLE: > 5 contractions in 10 minutes

(Note: term hyperstimulation is outdated and should not be used)

Intermittent monitoring

includes auscultation of the FHR:

Every 15 to 30 minutes during the active phase of labor

Every 5 to 15 minutes in the second stage of labor

Devices: fetoscope, Doppler ultrasound, pinard stethoscope

Auscultate FHR in conjunction w/ ctx for an entire ctx cycle

Continuous fetal monitoring

s a common practice in the United States.

In low-risk pregnancies, does not reduce risk of cerebral palsy or perinatal mortality as is often thought

With continuous fetal monitoring, a nurse evaluates:

Low-risk pregnancy: Every 30 minutes during the 1st stage of a low-risk woman and every 15 during the 2nd stage.

High-risk pregnancy: More frequent; ~every 15 min during 1st stage, every 5 min during 2nd stage (follow institution's policy)

External Fetal Monitoring (EFM)

Ultrasound transducer for FHR + tocotransducer to detect ctx

Internal Fetal Monitoring

Scalp (or spiral) electrode for FHR

Intrauterine pressure catheter (IUPC) for ctx - measures internal uterine pressure of ctx in Montevideo Units (MVUs)

FHR Baseline

average FHR rounded to 5 bpm

Normal: 110-160 (>160 = tachycardia; <110 = bradycardia)

Monitor between contractions, not including accels/decels, over 10 min

Variability

pattern of fluctuations in the baseline FHR assessed over a 10-min period; based on amplitude

Absent: no amplitude

Minimal: amplitude ≤5 bpm

Moderate: amplitude is 6-25 bpm

Marked: ≥26 bpm

Acceleration

increase in FHR from baseline

Before 32 wks GA: ≥10 bpm for at least 10 seconds (<2 min)

After 32 wks GA: ≥15 bpm for at least 15 seconds (<2 min)

Prolonged: >2 min, <10 min

Early Decelerations

decel: benign, associated w/ head compression; start, nadir & end mirrors ctx

Variable decelerations

decel: abrupt drop to nadir in <30 sec; decrease of >15 bpm for 15 sec to 2 min; may/may not be linked to ctx; associated w/ cord compression

Late decelerations

decel: gradual onset >30 sec w/ nadir occurring after peak of ctx; associated w/ placental insufficiency

Prolonged deceleration

decel: decrease of >15 bpm lasting 2-10 min

Sinusoidal Pattern

Smooth wave-like pattern of regular frequency and amplitude

Rare & ominous FHR pattern - Category III

FHR Category I

Baseline FHR 110-160

Moderate variability

No late or variable decelerations

Early decelerations optional

Accelerations optional

FHR Category II

Everything that does not fit the criteria for Category I or III

*considered "indeterminate" - requires continued monitoring and re-evaluation

FHR Category III

Absent variability AND:

Recurrent late decelerations -or-

Recurrent variable decelerations -or-

Bradycardia

FHR Interpretation Mnemonic

VEAL CHOP

Variable

Early

Acceleration

Late

Cord compression

Head compression

Oxygenated well

Placental insufficency

Category II Interventions

POISON

Position change

Oxygen administration

Increased fluids

Sterile vaginal examination

Oxytocin off

Notify Provider

A. Findings are consistent with category I FHR tracing and requires

no interventions.

A continuous fetal monitoring strip is evaluated and found to have a baseline heart rate of 130, moderate variability, no accelerations or decelerations, and contractions every 3 minutes lasting 60 seconds each. How does the nurse interpret these findings?

A. Findings are consistent with category I FHR tracing and requires no interventions.

B. Findings are consistent with category II FHR tracing and requires no interventions.

C. Findings are consistent with category III FHR tracing and requires no interventions.

D. Findings are consistent with category III FHR tracing and requires intrauterine resuscitation measures.