Ch. 14-Nursing Management During Labor and Birth

The purpose of performing a vaginal examination is to assess

the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status and to gather information on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding

When membranes rupture, the priority focus should be on assessing

fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse

Signs of intrauterine infection to be alert for include

maternal fever, fetal and maternal tachycardia, foul odor of vaginal discharge, and an increase in white blood cell count.

phases of contraction

Each contraction starts with a building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement).

Uterine contractions with an intensity of ___ mm Hg or greater initiate cervical dilation.

30

During active labor, the intensity usually reaches _____-_____ mm Hg.

50 to 80

Resting tone is normally between ____-____ mm Hg in early labor and between _____-_____ mm Hg in active labor.

5 and 10

12 and 18

description of how a contraction feels when palpating the fundus:

like the tip of the nose (mild), like the chin (moderate), or like the forehead (strong)

leopold's maneuver is

are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps.

how do you preform the leopold's maneuver

Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)?

Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.)

Maneuver 3: What is the presenting part?

Maneuver 4: Is the fetal head flexed and engaged in the pelvis?

amniotic fluid should be

clear when the membranes rupture

Cloudy or foul-smelling amniotic fluid indicates

infection

Green fluid may indicate

that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

Intermittent FHR monitoring

a primary method of fetal surveillance in labor, it is the practice of using a handheld Doppler or fetoscope for periodic assessment of the FHR

The best way to assess fetal well-being would be to start listening to the FHR at the end of the contraction (not after one) so that late decelerations could be detected

For low-risk women, the FHR and contraction characteristics should be assessed every

15 to 30 minutes in active labor and every 5 to 15 minutes while pushing, as well as before and after any digital vaginal examinations, membrane rupture, medication administered, and ambulation to the restroom

Guidelines for assessing FHR

Initial 10- to 20-minute continuous FHR assessment upon entry into labor and birth area

Completion of a prenatal and labor risk assessment on all clients

Intermittent auscultation every 30 minutes during active labor for a low-risk woman and every 15 minutes for a high-risk woman

During the second stage of labor, every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage

Continuous external monitoring

The tocotransducer is placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions

ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations.

Artifact

is used to describe irregular variations or absence of the FHR on the fetal monitor record that result from mechanical limitations of the monitor or electrical interference.

Continuous internal monitoring

usually indicated for women or fetuses considered to be at high risk.

Four specific criteria must be met for fetal spiral electrode monitoring to be used:

Ruptured membranes

Cervical dilation of at least 2 cm

Presenting fetal part low enough to allow placement of the scalp electrode

Skilled practitioner available to insert spiral electrode

fetal spiral electrode

the fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns

can accurately detect both short-term (moment-to-moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias. In addition, maternal position changes and movement do not interfere with the quality of the tracing.

category I FHR

Predictive of normal fetal acid-base status and do not require intervention

• Baseline rate (110-160 bpm)

• Baseline variability moderate

• Present or absent accelerations

• Present or absent early decelerations

• No late or variable decelerations

• Can be monitored with intermittent auscultation during labor

category II FHR

Not predictive of abnormal fetal acid-base status, but require evaluation and continued surveillance

• Fetal tachycardia (>160 bpm) present

• Bradycardia (

category III FHR

Predictive of abnormal fetus acid-base status and require intervention

• Fetal bradycardia (

Interventions for Category III Patterns

• Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern.

• Discontinue oxytocin or other uterotonic agent as dictated by the facility's protocol if it is being administered.

• Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression.

• Administer oxygen via nonrebreather face mask to increase fetal oxygenation.

• Increase the IV fluid rate to improve intravascular volume and correct maternal hypotension.

• Assess the client for any underlying contributing causes.

• Provide reassurance that interventions are to effect pattern change.

• Modify pushing in the second stage of labor to improve fetal oxygenation.

• Document any and all interventions and any changes in FHR patterns.

• Prepare for an expeditious surgical birth if the pattern is not corrected in 30 minutes.

Baseline FHR

refers to the average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia.

It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes.

Fetal bradycardia occurs when the FHR is

below 110 bpm and lasts 10 minutes or longer. Bradycardia may be benign if it is an isolated event, but it is considered an ominous sign when accompanied by a decrease in baseline variability and late decelerations.

​​Fetal tachycardia is a baseline FHR

greater than 160 bpm that lasts for 10 minutes or longer. Fetal tachycardia is considered an ominous sign if it is accompanied by a decrease in variability and late decelerations and usually represents asphyxia

Baseline variability

is defined as irregular fluctuations in the baseline FHR, which is measured as the amplitude of the peak to trough in beats per minute

Variability is described in four categories as follows:

Fluctuation range undetectable

Fluctuation range observed at fewer than 5 bpm

Fluctuation range from 6 to 25 bpm

Fluctuation range more than 25 bpm

Absent or minimal variability is typically caused by

fetal acidemia secondary to uteroplacental insufficiency, cord compression, a preterm fetus, maternal hypotension, uterine hyperstimulation, abruptio placenta, or a fetal dysrhythmia.

External electronic fetal monitoring cannot assess

variability accurately. Therefore, if external monitoring shows a baseline that is smoothing out, use of an internal spiral electrode should be considered to gain a more accurate picture of the fetal health status

Interventions to improve uteroplacental blood flow and perfusion through the umbilical cord include

lateral positioning of the mother, increasing the intravenous (IV) fluid rate to improve maternal circulation, administering oxygen at 8 to 10 L/min by mask, considering internal fetal monitoring, documenting findings, and reporting to the health care provider. Preparation for a surgical birth may be necessary if no changes occur after attempting the interventions.

Variability

beat to beat HR variations

Moderate viability indicates that

the autonomic and central nervous systems (CNSs) of the fetus are well developed and well oxygenated. It is considered a good sign of fetal well-being and correlates with the absence of significant metabolic acidosis

Risks with Internal Monitoring

Invasive

Must have ruptured membranes to place

Trauma

Discomfort when being placed

Risk for infection

Marked variability occurs when

there are more than 25 beats of fluctuation in the FHR baseline.

Causes of this include cord prolapse or compression, maternal hypotension, uterine hyperstimulation, and abruptio placenta.

Interventions include determining the cause if possible, lateral positioning, increasing IV fluid rate, administering oxygen at 8 to 10 L/min by mask, discontinuing oxytocin infusion, observing for changes in tracing, considering internal fetal monitoring, communicating an abnormal pattern to the health care provider, and preparing for a surgical birth if no change in pattern is noted

Benefits with Internal Monitoring

Maternal- more accurate measure of contractions

FSE early recognition of problems in the fetus

FSE More accurate, continuous tracing of fetal heart rate

Freedom of movement for mom, no belts around the abdomen

Periodic baseline changes

are temporary, recurrent changes made in response to a stimulus such as a contraction

accelerations and decelerations

Accelerations

are transitory abrupt increases in the FHR above the baseline that last less than 30 seconds from onset to peak. associated with sympathetic nervous stimulation

with elevations of FHR of more than 15 bpm above the baseline, and their duration is longer than 15 seconds but less than 2 minutes

They are generally considered reassuring and require no interventions. Accelerations denote fetal movement and fetal well-being and are the basis for nonstress testing.

Deceleration is

a transient fall in FHR caused by stimulation of the parasympathetic nervous system. Decelerations are described by their shape and association to a uterine contraction. They are classified as early, late, and variable only

Early decelerations are

visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. Early decelerations are not indicative of fetal distress and do not require intervention.

mirror peak of the contractions showing head compression

Late decelerations are

when the nadir happened after the contraction, shows oxygenation issue, giving oxygen is the last interventions, #1 intervention is to stop pitocin (my notes not from the book)

visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. They have a gradual waveform and can be recurrent, occurring with each contraction over a period of time. Conditions that may decrease uteroplacental perfusion with resultant decelerations include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia.

Variable decelerations present as

visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. usually occur abruptly with quick deceleration. They are the most common deceleration pattern found in the laboring woman and are usually transient and correctable.

associated with cord compression.

Prolonged decelerations are

abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes.

sinusoidal pattern is

described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for more than 20 minutes. Rare. to correct it, a fetal intrauterine transfusion would be needed

Umbilical cord blood analysis

drawn at birth provides an objective method of evaluating a newborn's condition, identifying the presence of intrapartum hypoxia and acidemia. This test is considered a good indicator of fetal oxygenation and acid-base condition at birth.

The normal mean pH value range is 7.2 to 7.3.

Fetal scalp stimulation

is performed to promote fetal movement with the hope that FHR accelerations will accompany the movement.

A well-oxygenated fetus will respond when stimulated (tactile or by noise) by moving in conjunction with an acceleration of 15 bpm above the baseline heart rate that lasts at least 15 seconds. This FHR acceleration reflects a pH of more than 7 and a fetus with an intact CNS.

Coping with Labor Algorithm

labor pain assessment tool

Nonpharmacologic measures for child birth

include continuous labor support, hydrotherapy, hypnosis, ambulation and maternal position changes, transcutaneous electrical nerve stimulation (TENS), acupuncture and acupressure, attention focusing and imagery, therapeutic touch and massage, breathing techniques, and effleurage.

gate control theory of pain

proposes that local physical stimulation can interfere with pain stimuli by closing a hypothetical gate in the spinal cord, thus blocking pain signals from reaching the brain

Hydrotherapy

the external use of any form of water for health promotion, may involve showering or soaking in a regular tub or whirlpool bath

The recommendation for initiating hydrotherapy is that the woman be in active labor (more than 6 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation. The woman's membranes can be intact or ruptured. The water temperature should not exceed body temperature.

potential risks associated with hydrotherapy including hyperthermia, hypothermia, changes in maternal heart rate, fetal tachycardia, and unplanned underwater birth.

Acupuncture

involves stimulating key trigger points with needles which causes the release of endorphins, reducing the perception of pain

Acupressure

involves the application of a firm finger, thumb, knuckles, or massage used on similar points to those used in acupuncture to reduce the pain sensation.

Heat is typically applied to

the woman's back, lower abdomen, groin, and/or perineum.

Cold therapy, or cryotherapy, is usually applied on the

woman's back, chest, and/or face during labor

Effleurage is

a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions. It is used as a relaxation and distraction technique from discomfort

why is massage helpful?

Because touch receptors go to the brain faster than pain receptors, massage—anywhere on the body—can block the pain message to the brain.

Breathing techniques

Three levels may be taught, each beginning and ending with a cleansing breath or sigh after each contraction.

In the first pattern, also known as slow-paced breathing, the woman inhales slowly through her nose and exhales through pursed lips. The breathing rate is typically six to nine breaths per minute.

In the second pattern, the woman inhales and exhales through her mouth at a rate of four breaths every 5 seconds. The rate can be accelerated to two breaths per second to assist her to relax.

The third pattern is similar to the second pattern except that the breathing is punctuated every few breaths by a forceful exhalation through pursed lips.

Neuraxial analgesia/anesthesia is

the administration of analgesic (opioids) or anesthetic (capable of producing a loss of sensation in an area of the body) agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain.

Systemic analgesia are which medication classes

opioids

antiemetics

benzodiazepines

Opioids used during labor

butorphanol (Stadol)

nalbuphine (Nubain)

meperidine (Demerol)

morphine

fentanyl (Sublimaze)

Antiemetics used during labor

hydroxyzine (Vistaril)

promethazine (Phenergan)

prochlorperazine (Compazine)

Benzodiazepines used during labor

diazepam (Valium)

midazolam (Versed)

go read DRUG GUIDE 14.1 Common Agents Used for Systemic Analgesia

p. 488

Inhaled analgesics

labor pain, half nitrous oxide gas (50%) is mixed with half oxygen (50%) and breathed through a mask or mouthpiece.

Potential side effects of N2O/O2 include nausea and vomiting, dizziness, and dysphoria, although these are rare. No FHR abnormalities though

Regional analgesia/anesthesia

generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord

The routes for regional pain relief include epidural block, combined spinal-epidural, local infiltration, pudendal block, and intrathecal (spinal) analgesia/anesthesia.

Epidural analgesia

the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space

increase the duration of the second stage of labor and may increase the rate of instrument-assisted vaginal deliveries as well as that of oxytocin administration

Make sure patient is hydrated because of possible hypotension

contraindications for an epidural

contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects, cardiac disease, obesity, infections, and hypovolemia. It is also contraindicated for the woman who is receiving anticoagulation therapy.

complications of an epidural

include nausea and vomiting, hypotension, fever, pruritus, intravascular injection, maternal fever, allergic reaction, and respiratory depression. Effects on the fetus during labor include fetal distress secondary to maternal hypotension

nursing intervention for an epidural

Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help minimize hypotension.

Combined spinal- epidural analgesia

An opioid without a local anesthetic is injected into this space.

is advantageous because of its rapid onset of pain relief (within 3 to 5 minutes) that can last up to 3 hours, also allows the woman's motor function to remain active

ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact

allows for ambulation

combined spinal- epidural analgesia complications

Complications include maternal hypotension, intravascular injection, accidental intrathecal blockade, postdural puncture headache, pruritus, inadequate or failed block, maternal fever, and pruritus. Hypotension and associated FHR changes are managed with maternal positioning (semi-Fowler position), IV hydration, and supplemental oxygen

Patient-controlled epidural analgesia allows what

This method allows the woman to have a sense of control over her pain and reach her own individually acceptable analgesia level.

Local infiltration involves

the injection of a local anesthetic, such as lidocaine, into the superficial perineal nerves to numb the perineal area. This technique is done by the physician or midwife just before performing an episiotomy or before suturing a laceration.

does not alter the pain of uterine contractions, but it does numb the immediate area of the episiotomy or laceration.

does not cause side effects for the woman or her newborn.

Pudendal nerve block

the injection of a local anesthetic agent (e.g., bupivacaine, ropivacaine) into the pudendal nerves near each ischial spine. It provides pain relief in the lower vagina, vulva, and perineum

used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor. It must be administered about 15 minutes before it would be needed to ensure its full effect. Neither maternal nor fetal complications are common.

Spinal (intrathecal) analgesia/ anesthesia

injection of an anesthetic "caine" agent with or without opioids into the subarachnoid space to provide pain relief during labor or cesarean birth.

the contraindications are similar to those for an epidural block. Adverse reactions for the woman include hypotension and spinal headache.

General anesthesia

typically reserved for emergency cesarean births when there is not enough time to provide spinal or epidural anesthesia or if the woman has a contraindication to the use of regional anesthesia.

All anesthetic agents cross the placenta and affect the fetus

primary complication with general anesthesia is fetal depression, along with uterine relaxation and potential maternal vomiting and aspiration.

Nursing care in the first stage of labor

admission history (reviewing the prenatal record); checking the results of routine laboratory tests and any special tests such as chorionic villi sampling, amniocentesis, genetic studies, and biophysical profile done during pregnancy; asking the woman about her childbirth preparation (birth plan, classes taken, coping skills); and completing a physical assessment of the woman to establish baseline values for future comparison

what are the highest priorities of nursing care in the first stage of labor

highest priorities include assessing FHR, assessing cervical dilation and effacement, and determining whether membranes have ruptured or are intact.

When completing a phone assessment, include questions about:

Estimated date of birth to determine if term or preterm

Fetal movement (frequency in the past few days)

Other premonitory signs of labor experienced

Parity, gravida, and previous childbirth experiences

Time from start of labor to birth in previous labors

Characteristics of contractions, including frequency, duration, and intensity

Appearance of any vaginal bloody show

Membrane status (ruptured or intact)

Presence of supportive adult in household or if she is alone

Laboratory studies

usually include a urinalysis via clean-catch urine specimen and complete blood count

Assessments during Latent Phase (0-6 cm)

VT- q 30-60 minutes

temp - q 4 hours; more frequently if membranes are ruptured

contractions- Every 30-60 minutes by palpation or continuously if EFM

FHR- Every hour by Doppler or continuously by EFM

Vaginal exam- Initially on admission to determine phase and as needed based on maternal cues to document labor progression

Behavior/psychosocial- With every client encounter: talkative, excited, anxious

Assessments during Active Phase (6-10 cm)

VT- q 15-30 minutes

temp - q 4 hours; more frequently if membranes are ruptured

contractions- Every 15-30 minutes by palpation or continuously if EFM

FHR- Every 15-30 minutes by Doppler or continuously by EFM

Vaginal exam- As needed to monitor labor progression

Behavior/psychosocial- With every client encounter: self-absorbed in labor; intense and quiet now

Maternal Signs of Transition to Second Stage

Increased apprehension or irritability

Spontaneous ROM

Increased bloody show

Low grunting sounds

Pressure on pelvic floor

Involuntary bearing down effort (Ferguson reflex)

Sudden appearance of sweat on upper lip

Current evidence for management of the second stage of labor supports

the practices of delayed pushing, spontaneous (nondirected) pushing, and maternal choice position

Episiotomy

is an incision made in the perineum to enlarge the vaginal outlet and theoretically to shorten the second stage of labor

Restrictive use of episiotomy has been recommended by ACOG given the risks of the procedure and unclear benefits of routine use

Second Stage of Labor (Birth of Neonate)

VT- Every 5-15 minutes

FHR- Every 5-15 minutes by Doppler or continuously by EFM

contractions/uterus- Palpate every one

bearing down/pushing- Assist with every effort

Vaginal discharge- Observe for signs of descent—bulging of perineum, crowning

Behavior/psychosocial- Observe every 15 minutes: cooperative, focus is on work of pushing newborn out

Third Stage of Labor (Placenta Expulsion)

VT- Every 15 minutes

FHR- Apgar scoring at 1 and 5 minutes

contractions/uterus- Observe for placental separation

bearing down/pushing- None

Vaginal discharge- Assess bleeding after expulsion

Behavior/psychosocial- Observe every 15 minutes: often feelings of relief after hearing newborn crying; calmer

Fourth Stage of Labor (Recovery)

VT- Every 15 minutes

FHR- Newborn—complete head-to-toe assessment; vital signs every 15 minutes until stable

contractions/uterus- Palpating for firmness and position every 15 minutes for first hour

bearing down/pushing- None

Vaginal discharge- Assess every 15 minutes with fundus firmness

Behavior/psychosocial- Observe every 15 minutes: usually excited, talkative, awake; needs to hold newborn, be close, and inspect body

Immediate care of the newborn

the newborn is placed under a radiant warmer, dried, assessed, wrapped in warmed blankets, and placed on the woman's abdomen for warmth and closeness. In some health care facilities, the newborn is placed on the woman's abdomen immediately after birth and covered with a warmed blanket without being dried or assessed

Secure two identification bands on the newborn's wrist and ankle that match the band on the mother's wrist to ensure the newborn's identity.

Apgar

(appearance, pulse, grimace, activity, and respiration) score at 1 and 5 minutes. The Apgar score assesses five parameters—(1) heart rate (absent, slow, or fast), (2) respiratory effort (absent, weak cry, or good strong yell), (3) muscle tone (limp, or lively and active), (4) response to irritation stimulus, and (5) color—that evaluate a newborn's cardiorespiratory adaptation after birth. The newborn is assigned a score of 0 to 2 in each of the five parameters. The purpose of the Apgar assessment is to evaluate the physiologic status of the newborn

Monitoring placental separation by looking for the following signs

Firmly contracting uterus

Change in uterine shape from discoid to globular ovoid

Sudden gush of dark blood from vaginal opening

Lengthening of umbilical cord protruding from vagina

Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time)

Assessing for any perineal trauma, such as the following, before allowing the birth attendant to leave:

Firm fundus with bright red blood trickling: laceration

Boggy fundus with red blood flowing: uterine atony

Boggy fundus with dark blood and clots: retained placenta

Inspecting the perineum for condition of episiotomy if performed

Assessing for perineal lacerations and ensuring repair by birth attendant

If the fundus is displaced to the right of the midline, suspect a ____ _______ as the cause.

full bladder

During the first hour after birth, vital signs are taken every _________________________

15 minutes, then every 30 minutes for the next hour if needed. The woman's blood pressure should remain stable and within normal range after giving birth. A decrease may indicate uterine hemorrhage; an elevation might suggest preeclampsia.

Intensity of contractions cannot be monitored with an ________

external device, only the internal one and palpation

VEAL CHOP

V- Variable C- Cord Comphression

E- Early Decels H- Head Compression

A- Accelerations O - OK

L-Late Decels P - Placenta

Version

Use ultrasound to:

-Determine fetal position

-Location of placenta

-Location of umbilical cord

Monitor FHT before and after

Terbutaline

Attempt to turn fetus by external manipulation when baby is breech, 36 weeks gestation, add this in from slides. They will be given terbutaline (contraindicated if the pulse is high)

Induction

Initiate uterine contractions (start labor)

Can use cytotec and pitocin to induce