week3: labor and delivery

what labor is supposed to look like

List the physiologic changes before labor

backache, loss of weight 1-3.3lb, lightening energy burst, cervical ripening

What distinguishes true labor from false labor?

cervical dilation and effacement

First stage(early) of labor facts

0-5cm, frequency is 2-30 min, duration is 30-40 seconds

First stage of labor patient observation

scant amount of brownish discharge, pale pink mucous. talkative and calm and can walk and talk through contractions. can be apprehensive

First stage of labor (active phase)

6- 10 cm, contractions are stronger, frequency is 1.5-5 min→2-3 min, duration is 40-90 seconds

dilation and effacement→ complete dilation, will feel the urge to pushf

first stage of labor in active phase patient observation

anxiety and restlessness increase as contractions become stronger, N/V, will need to have a bowel movement but this is just the baby moving

When are we in 2nd stage of labor?

in full dilation until the birth of baby

third stage of labor

placental separation and expulsion

schultze presentation

the shiny surface of the placenta comes first

Duncan presentation

the dull surface of the placenta comes first

Fourth stage is also called

recovery phase

Spontaneous rupture (SROM)

naturally rupturing of the membranes

Amniotomy (AROM)

artificial rupture of membranes

how long does labor usually begin after the rupture of membranes?

within 24 hours

what will happen to mom if membranes ruptured but its been past 24 hours before birth of baby??

infection

what is an immediate assessment for the nurse following the rupture if membranes

assess for FHR for abrupt decelerations to rule out umbilical cord prolapse

Assessment of the amniotic fluid

watery, clear, slightly yellow tinge, volume is 700-100mL, with nitrazine paper confirming as a deep blue color with a PH of 6.5-7.5

list the 5 P’s

passenger, passageway, powers, position, psychological

What consist of the P (Passager)

consist of the baby’s head, presentation, lie, attitude, and position affecting baby’s ability to navigate the birth canal, also placenta

facts about the size of the baby’s head

sutues (the skinny flexeble part) and Fontanels (the fatter part of the flexeble head) molding can occur during labor and it resumes normal shape after 3 days after birth

facts about the baby presentation

how is the baby positioned for birth, cephalic, breech, or shoulder. presenting part refers to the part of the baby closest to the internal part of cervix

facts about the lie

how the baby is positioned either transverse or parallel. if a baby is transverse mom requires a C-section. if baby is a breech then its also recommended for a C-section

facts about attitude

fetal flexion is when chin is flexed into chest and extremities is flexed into torso,

fetal extension is when chin extended away from chest and extremities are extended

facts about fetal position

tells healthcare workers how baby is positioned, first letter is the side of moms pelvis, second letter is the presenting part of baby, third letter is references the part of the moms pelvis

facts about the station

a measurement in fetal decent in cm.

station 0 is at the level of ischial spines

-stations are above the ischial spines

+stations are under the ischia spines

2nd P passage way facts

the birth canal composed of bony pevlis, cervix, pelvic floor, vagina, and introitus

Powers (primary)

Uterine contractions cause effacement and dialationp

powers (secondary)

the involuntary urge to push and voluntary bearing down that helps push baby out

the mom position facts

mom should engage in frequent position changes during labor to increase comfort, relieve fatigue and promote circulation. gravit aids in fetal descent(uptight, sitting, kneeling, and squatting).

dr. may be slightly restrictive b/c we need to monitor baby

Leopold maneuvers

externally positioning the baby

tocotransducer (toco)

measures contractions

When is group B steptococcus screened

36-38 weeks. if positive we are doing IV antibiotics

Nursing actions during Intrapartum

Assess om VS, and check Mom’s temo every 2 hours

assess FHR

assess uterine contractions characteristics; frequency, duration, intensity, resting tone of uterine contractions

Why are we checking for maternal temperature

checks for infection if her temperature is above 100.5

What goes into a vaginal examination (SVE)?

effacement, cervical dilation, descent of the fetus in station, fetal position, membranes are intact or ruptured

Post procedure Nursing assessments

maternal VS, fundus, Lochia, Perineum, Urinary output, maternal/newborn baby-friendly activates

During the 4th stage what are AAP and ACOG recomendations for vital signs for mom?

BP and Pulse- every 15 min for first two hours after birth

temp every 4 hours for the first 8 hours after birth then every 8 hours

assess fundus and lochia every 15 min for first hour

why should we massage the uterine fundus or admin oxytocic during post procedure?

to maintain uterine tone and prevent hemorrhage

First stage of labor the source of pain

internal visceral pain felt as back and leg pain

coming from dilation, effacement, and stretching of cervix, contractions

second stage of labor the source of pain

somatic pain that occurs with fetal descent and expulsion

coming from pressure and distention from the vagina and perineum(burning, splitting, and tearing), pressure and pulling of the pelvic structures, and lacerations of soft tissues like the cervix, vagina and perineum)

third stage of labor the source of pain

with expulsion of placenta, is mostly visceral pain. pressure and pulling of pelvic structures

fourth stage of labor source of pain

distention and stretching of vagina and perineum during the second stage, splitting, burning, and tearing sensations

what is the main use of nonpahrmalogical pain

to reduce anxiety, fear, and tension

gate-control theory of pain

sensory nerve pathways allowing a limited number of sensations to travel at any given time.

cognitive interventions of nonpharmacological pain management

childbirth education, Lamaze, doulas

assessing for hyperventilation, lightheadedness, and tingling of fingers

sensory stimuli strategies interventions of nonpharmacological pain management

aromatherapy, breathing techniques, imagery, music, focal points, subdued lighting

Cutaneous Stimulation strategies

back rubs and massage, walking, rocking, application of heat or cold, frequent maternal position changes

Cutaneous Stimulation strategies: Efflurage

gentle circular motions in the abdomen in rhythm with breathing during contraction

Cutaneous Stimulation strategies: Sacral counterpressure

pressure applied using the heel of the hand or fist against the sacral area to counteract pain in the lower back

Cutaneous Stimulation strategies: Hydrotherapy

pool or shower that can increase maternal endorphin levels

pharmacological pain management: Analgesia Sedatives (barbiturates)

using during the early or latent phase

pharmacological pain management: Opioid Analgesics

given during early part of active labor

pharmacological pain management: regional blocks, Pudendal

transvaginal injection of local anesthetic in perineal area

pharmacological pain management: regional blocks, Epidural

administered during labor

pharmacological pain management: regional blocks, Spinal

used for cesarean

What does admin of nitrous oxide most benefit maternal for?

reduces the perception of pain

Epidural Catheter placement

local anesthetic, bupivacaine, or analgesic injected into epidural space at lv 4th and 5th of vertebrae.

it will remove pain but not pressure sensations. the medication can be continuous or intermittent or patient-controlled (PCEA)

Epidural Adverse effects

Maternal hypotension, fetal bradycardia, fever, itching, inability to feel the urge to void, urinary retention, loss of bearing down reflex, prolonged labor

Epidural nursing actions

admin IV bolus →aids with hypotension
make position and have steady for correct placement
tilt or remain side-lying to avoid supine hypotension
monitor maternal BP, HR, RR, O2
assess FHR continuously
maintain IV and have O2 and suction available → for their N/V
assessing for ortho hypotension → preparing to admin IV vasopressor(ephedrine) positioning laterally, IV fluids, initiate O2
side rails, (SCD), insert a foley catheter, and coach in pushing

Spinal Anesthesia: Adverse effects

Maternal hypotension, fetal bradycardia, loss of bearing down reflex, potential headache from leakage of cerebrospinal fluid at puncture site, there is a higher incidence of uterine atony following birth → bc pain is blocked

Spinal Anesthesia: nursing actions

Assess maternal VS every 10 min
maternal hypotension → manage by IV fluid bolus as prescribed, positioning patient laterally, increasing the rate of fluid IV, initiate O2
assess uterine contractions, lv of anesthesia, FHR patterns, raise side rails

General anesthesia: nursing actions

use as a last option

M mom VS/ M FHR patterns, mom should have nothing by mouth, ensure IV infusion in place. Apply SCD, premedicate mom with oral antacid to nutralize somatch acid contents. admin histamine 2 recepor antagonist (famotidine) to decrease gastric acid production

admin metoclopramide to increase gastric emptying, place wedge on hips to displace uterus. maintain an airway

Leopold Maneuvers

external palpations of maternal uterus through abdominal wall to determine fetal lie , attitude, and resenting part, degree of descent

guidelines for listening to fhr during latent phase (<4cm)

hourlygu

guidelines for listening to FHR during latent phase(4-5cm)

every 15-30 min

guidelines for listening to FHR during active phase

every 15-30 min for active

guidelines for listening to FHR during the second stage

every 5-15 min

indications for an EFM

determines active labor
rupture of membranes
preceding and subsequent to ambulation
prior or following admin of change in med analgesia
at speak action of anesthesia following vaginal examination
following expulsion of an enema
after urinary catheterization
abnormal or excessive uterine contractions

what is a normal fetal heart rate?

110-160bpm

diagnostic measures to determine tacky or bradycardia

FHR being above or below expected range for 10 min or longer

Non-reassuring FHR are associated with___ and include the following

hypoxia,
fetal brady, tacky, absence of FHR variability, late decelerations, variable decelerations

complications or causes for feal bradycardia

Uteroplacental insufficiency, umbilical cord prolapse, maternal hypotension, prolonged umbilical cord compression, fetal congenital heart block, anesthetic medications, viral infection, maternal hypoglycemia, fetal heart failure, maternal hypothermia

Nursing interventions for FHR bradycardia

discontinue oxytocin, assist mom to side-lying position, admin O2 at 10 L/min via non-rebreather face mask, insert an IV catheter and admin fluids, admin a tocolytic med. Notify provider → if your interventions did not stabilize mom and baby

complications or causes of FHR tachycardia

Maternal infection, intrauterine infection, fetal anemia, fetal dysrhythmias, maternal use of cocaine, caffeine, or methamphetamines, maternal dehydration, maternal or fetal infection, maternal fever(>100.5), maternal hyperthyroidism

nursing interventions for FHR tachycardia

admin prescribed antipyretics for maternal fever if present, admin o2 by mask at 10L/min non-rebreather face mask. admin IV fluid bolus

FHR variability

fluctuations in FHR baseline

causes that decrease or loss of FHR variability

med that depress the CNS (barbiturates, mag sulf, gen anesthesia, fetal hypoxemia and metabolic acidemia, fetal sleep cycle(this loss does not last longer than 30 min), congenital abnormalities

nursing interventions for FHR that has loss of variability

stimulate fetal scalp. Assist provider with application of scalp electrode. place client in left- lateral position

moderate variability

marked variability

absent or non-reasuring variability

minimal variability

accelerations in FHR

FHR patterns: Accelerations

healthy fetal/ placental exchange
indicates a reactive nonstress test.

variable deceleraction of FHR

slowing of FHR of 15 bpm or more below baseline for at least 15 seconds

causes or the complications that cause deceleration of FHR

umbilical cord prolapse, short cord, prolapse cord, knot in cord, nuchal cord(around the fetal neck)

nursing interventions if variable decelerations are found in FHR

reposition the client from side to side or knee-chest
discontinue o2
admin oxygen by mask at 10-15L/min via non-rebreather face mask
perform or assist with a vaginal examination
Assist with an amnioinfusion if prescribed

early deceleration of FHR

slowing of FHR at the start of a contraction and returns to baseline at the end of contraction

cause or complications that cause early deceleration of FHR

compression of the fetal head resulting from: Uterine contractions, vaginal exam, fundal pressure, placement of internal monitoring
no intervention required, normal labor

Late deceleration of FHR

slowing of the FHR that returns well after contraction has ended

cause or complication that cause late deceleration of FHR

Uteroplacental insufficiency,
maternal hypotension, placenta previa, abruptio placentae, uterine tachysystole with oxytocin,
preeclampsia
late or post term pregnancy
maternal diabetes mellitus

Nursing interventions for late decelerations of FHR

Place the client in a side-lying position
Insert an IV catheter if not in place and increase rate of IV fluid admin
discontinue oxytocin if being infused
admin oxygen mask at 10-15L/min via nonrebreather face mask
elevate the clients legs
notify provider
prepare for assisted vaginal birth or C-section

prolonged deceleration

advantage of a continuous internal fetal monitoring

early detection of abnormal FHR patterns
accurate assessment of FHR variability
accurate measurement of uterine contraction intensity
Allows greater maternal freedom of movement because tracing s not affected by fetal activity, or maternal positions

disadvantages of continuous internal fetal monitoring

membranes need to have ruptured to use internal monitoring
cervix must be dilated to a min of 2 to 3 cm
presenting part must have descended to place electrode
potential risk of injury to fetus if it is not placed properly
a provider, nurse practitioner/midwife, or specially trained RN must preform this procedure
risk of infection to client and fetus

Category l

‘A perfect baby”
baseline in FHR is 110-160/min
baseline FHR variability is moderate
Accelerations: present or absent
early decelerations": present or absent
variable or late decelerations: absent

Category ll

baseline rate: tacky or brady cardia
variability: minimal, absent, or marked variability
decelerations: prolonged FHR deceleration ≥2min but <10min/ late deceleration with moderate variability/ variable deceleration with minimal or moderal baseline variability
accelerations: absent

Category lll

“Abnormal must deliver”
sinusoidal pattern
absent baseline FHR with recurrent variable or late decelerations, bradycardia

Tachysystole

uterine contractions more than 5 min of contractions in 10 min averaged over a 30 min window

FHR pattern VEAL mnemonic

V (variable deceleration)
E (early deceleration)
A (acceleration)
L (late deceleration)