Ch 15 nursing care during labor & birth

when to go to the hospital

• contractions

• ruptured membranes

• bright-red bleeding

• decreased fetal movement - monitor!

• other concerns/feelings something may be wrong

umbilical cord prolapse

• Primary risk @ time of rupture is that it w/ slip down w/ fluid gush 

• Can be compressed between presenting part & pelvis 

  • Obstruction of blood dlow 

• FHR assessed for at least 1 full min after amniotomy/SROM

  • Big changes promply reported 

  • Prolonged decels/bradycardia 

contraction alert!

• all for 1hr!

  • regular

  • 5 min apart

  • last 1 min

• only the general rate - fast laborer? come earlier!

ruptured membrane alert!

• gush/trickle of fluid from vagina

  • can also be pee → baby kicking bladder

• happens w/ or w/o contractions

• stays in hospital - infection risk

nursing responsibility during admission

• establish therapeutic relationship

  • convery confidence

  • assign a primary nurse

  • use touch for comfort

  • respect cultural values

  • determine family expectations

confidence as a nurse

• trust me! ill take care of you!

  • makes them trust u more

touch for comfort

• its okay to touch a pt for support!

• hugs/holding hands if wanted

respecting of cultural values

• in alignment w/ rules & regulations in hospital

determination of family expectations

• what does mom want/expect?

  • delivery style, breast/bottlefeeding, uncertainties

  • work w/ the pt!

conditions associated w/ fetal compromise

• FHR outside normal limits

• meconium-stained amniotic fluid

• cloudy, yellowish, foul smelling amiotic fluid

• excessive frequency/duration of contractions

• incomplete uterine relaxation

• maternal hypotension/hypertension

• maternal fever

FHR outside normal limits & fetal compromise

• anything out of 110-160

• loss of variability

• why? meds?

meconium-stained amniotic fluid & fetal compromise

• baby stool

• deep suction needed when baby reaches perineum b4 1st breath

  • prevents infection from entering alveoli

• amiotic fluid not clear?

  • green? black? brown?

bad amiotic fluid & fetal compromise

• cloudy, yellowish, foul smelling

• pus indication

  • infection! chorioamnionitis

excessive frequency/duration of contractions & fetal compromise

• tachysystole!

  • oxygenation?

incomplete uterine relaxation & fetal compromise

• staying rigid/contracted

  • O2 concerns -

maternal hypotension/hypertension & fetal compromise

• find out why!

  • intervene asap

maternal fever & fetal compromise

• esp when baby tachycardic

• why?

  • prolonged labor/rupture?

amniotomy

• artificial rupture of membranes (AROM)

• indication & augementation

• risks

• done by DR or nurse-midwife

• nursing considerations

spontaneous rupture of membranes

• happen on own!

• SROM!

AROM indication & augementation

• inducing labor

• augmenting labor

• allowing for internal fetal monitoring

AROM & labor induction

• baby head then moves down to cervix → irritates it → contraction!

  • helps progress labor

AROM & labor augmentation

• laboring/contracting w/ no cervical change?

  • moves head & intensifies contractions

internal fetal monitoring & AROM

• for FSE, IUPC

• still intact? can’t get in!

AROM risks

• umbilical cord prolapse

• infection

• abruptio placentae

umbilical cord prolapse & AROM

• if baby’s head isnt well applied to cervix

• cord comes down before baby’s head does

infection & AROM

• water is broken too long

• poor sterile technique

abrupto placentae & AROM

• can happen if pt has tons of fluid

  • pressure suctions/vaccums placenta → pulls it loose!

physician & AROM

• usually done by physican/nurse-midwife

• amiohook snags memebrane

  • looks like crochet hook

  • inserted w/ vaginal exam

• snag the bag!

• also finger pop option - finger glove w/ razor sharp edge

nursing considerations w/ AROM

• obtain baseline info

• assist w/ procedure

  • gather equipment, place absorbent pads under pt

• provide care after procedure

• note fluid quality, quantity, timing since rupture

  • lots of fluid? just a little?

AROM nurse assist

• gather equipment, place absorbent pads under pt

  • Extend from client waist to knees 

• Explain no more painful than vaginal exam 

• Membrane hook 

• Sterile gloves & lube 

AROM baseline info

• FHT

• accelerations

• distress? monitor ASAP after sac broken!

• Provier checks dilation, effacement, station, & presenting part first 

  • Deferred w/ high presenting part

AROM aftercare

• assess FHT

• clean client

• change pads

• make pt more comfy

AROM fluid qualities

• blood

• color

• odor

external cephalic version

• AKA version/ECV

• when baby in bad fetal lie

• HCP rotates baby by pushing on outside

  • trying to move head → pelvis

• not super common bc of lawsuit risk

  • lots of complications/risks

• takes tons of strength !

• soooo painful

external cephalic version indications

• changing fetal position!

  • breech, shoulder, transverse lie

  • oblique presentations

• changed to cephalic!

internal cephalic version indications

• to change the position of a 2nd twin during vaginal birth

external cephalic version contraindications

• uterine malformations

• previous C-section birth

• placenta abnormalities

• 3rd trimester bleeding

• cephalopelvic disproportion

• multifetal gestation

• oligohydramnios

• IUGR

• uretoplacental insuffiency

• engagement of fetal head into pelvis

external cephalic version complications

• occur in 1-2%

• FHR changes common

  • usually returns to normal

• umbilical cord entanglement

• fetal hypoxia

• abruptio placentae

• can create maternal sensitization to fetal blood type

external cephalic version nursing considerations

• provide info! educate!

• promote maternal & fetal health

  • assess woman & fetus

    • b4 & after

• try & help reduce anxiety

external cephalic version pain

• crazy

• give terbutaline

  • helps relax uterine muscle - tocolytic

• TONS of pressure moving the baby

• risk of breaking water/placenta abruption - may induce labor

  • OR on standby

labor augmentation

• requires mom to be showing signs of labor already

labor induction

• Artificial methods to stimulate contractions 

• Induction increasingly more popular 

• Increased c-section rate 

  • Risk decreased when cervix is already partly dilated & effaced

labor induction & augmentation indications

• hostile intrauterine envrionment

• preterm rupture of membranes when term (PROM)

• postterm pregnancy - placental issues

• chorioamnionitis

• HTN - severe preeclampsia

• maternal medical conditions that worsen w/ pregnancy continuation

  • GDM, marginal placental previa

• fetal demise

• really any complications/medical issues

• must be 39wks for elective induction !

  • decided by AWHONN

  • Not recommended 

    • Higher c-section & respiratory issue rate 

• Augmentation when labor has started, but then slowed/stopped

chorioamnionitis

• infection & inflammation of amniotic sac

• causes sick baby - they floatin around in this

labor induction & augmentation contraindications

• complete placental previa

• vasa previa

• umbilical cord prolapse → get to c-section

• abnormal fetal presentation

• active gential herpes

• previous uterine surgery

• breech/transverse presentation - c-section!

• overdistended uterus

  • multifetal pregnancy, polyhydramnios

• severe maternal conditions like heart disease & severe HTN

• fetal presenting part above pelvic inlet

vasa previa

•  umbilical cord vessels branching in amniotic membrane

gential herpes + labor induction & augmentation

• contraindicated esp w/ lesions on vagina & anus

  • c-section done

multifetal pregnancies

• typically have early deliveries despite overdistended uterus risk

severe maternal conditions + labor induction & augmentation

• heart disease

• severe HTN

  • can be close to seizing

  • too much stress! - on heart OR brain

labor induction risks

• Increased uterine activity can decrease placetal perfusion 

• Uterine ruptire - more likely w/ overdistention 

• Water intoxication - esp w/ hypotonic IV fluids w/ oxytocin 

  • Monitor I&Os

• Chorioamnionitis

• C-section birth 

• Postpartum hemorrhage 

labor induction & augmentation techniques

• determination when indicated

• cervical ripening

• oxytocin admin

labor induction & augmentation determination

• cervical assessment!

• bishop score

  • many, many factors

  • Dilation, effacement, consistency, position, fetal station 

  • Higher than 8? Go vag 

labor induction & augmentation + cervical ripening

• pharmacologic methods

• mechanical methods

pharmacologic cervical ripening

• prostaglandin

  • Gel! Tablet! 

  • Given w/ fetal monitoring 

• Specifically misoprostol 

  • Off label use 

  • Low cost, room temp stable 

  • tabs

• Dont give to pts w/ past uterine surgery!

• Can cause tachysystole! 

• Have pt lay recumbent for 30 min 

mechanical cervical ripening

• transcervical balloon catheter

• membrane stripping

• hydoscopic inserts

transcervical balloon catheter

• foley ! w/o tubes!

• balloon at least 1/2cm w/ 30-60mL fluid

  • pressure irritates cervix → labor hormones start releasing

• falls out at abt 3cm dilated

• pull tight against cervix to secure

  • tape to moms leg

hydroscopic inserts

• Absorb water & swell 

  • Dilate cervix 

  • Speculum placement 

membrane stripping

• go in & take extra membrane thickness

  • will break water

oxytocin + labor induction & augmentation

• starts contractions

• dilute in isotonic solution

• secondary (PB) infusion

  • insert into primary line

• start slowly, gradually increase

• monitor frequently!

  • uterine activity, FHR, FHT

• Receptor cites can become desensitized -> continual rate increase can cause abnormal uterine activity 

• Reduce as active phase reached!

• Can be restarted PRN

  • Start at same or lower dose if before 40 min 

• Take BP & HR! Q1h! 

•  Can make contractions happen fast!

episiotomy

• incision of perineum just before birth 

  • Perceived benefits not proven true

episiotomy indications

• Rapid resolution of shoulder dystocia 

  • Fetus lodged under symphysis 

• Vaccum extractor-assisted/forcepts-assisted birth 

• OP positioned fetus 

• Breech delivery 

• Macrosomia 

• Short perineal length

episiotomy risks

• Infection

• Perineal pain - lasts longer 

  • Impairs sex resumption 

• Risk for 3rd & 4th degree tears w/ midline ones 

  • Fecal incontinence 

  • More pain

  • Blood loss 

  • Infection 

• Increases future tear risk

episiotomy technique

• When fetus has crowned to 3-4cm 

  • Medial

  • mediolateral

midline episiotomy

• Less blood loss, little scarring, less pain 

• Can extend into anus 

• Limiited enlargement bc of anus

mediolateral episiotomy

• More enlargement possible, little risk of extension ot anus, protection from feces, less time to repair 

• More blood loss, more pain, more scarring, prolonged painful intercourse

episiotomy nursing considerations

• Can be avoided or limited sometimes 

• Have pt push upright! 

• Delay push until pressure comes 

• Encourage breathing 

• Daily perineal massage from wk 34! 

• Monitor 

  • Hematoma, edema 

  • Incision infection 

• Cold applications for 1st 24 hr -> heat 

vaginal birth leading to c-section indications

• shortened 2nd srage of labor

• maternal indications

• fetal indications

vaginal birth leading to c-section maternal indications

• exhausion

• inability to push effectively

• infection

• cardiac/pulmonary disease

  • don’t want pt pushing!

vaginal birth leading to c-section fetal indications

• failure of presenting part to descend into pelvis

  • cephalopelvic disproportion (CPD)

• partial separation of placenta (abruption)

• non-reassuring FHR patterns

c-section indications

• dystocia

• cephalopelvic disproportion

• HTN

• maternal disease

• active gential herpes

• previous uterine surgical procedures

• persistent indeterminate/abnormal FHR patterns

• prolapsed umbilical cord

• fetal malpresentations

• hemorrhagic conditions

• maternal request

HTN & c-section

• most MDs wont go this far just bc of this

  • treatment attempted first!