Ch. 16, 18, 19
Module 4 - Dr. Kathryn Zeigler, FNP-C
Chapter 16 - Giving Birth
Physiological Effects of the Birth Process
Maternal Response
Reproductive: Key changes in the reproductive system during labor.
Respiratory System: Increased respiratory rate and changes in lung capacity.
Cardiovascular System:
Shift in blood volume: Approximately a gain of 1-2 L during pregnancy.
Risk of hyperventilation during labor and delivery.
Gastrointestinal (GI) System: Reduced gastric emptying during labor.
Urinary System: Decreased sensation of a full bladder.
Hematopoietic:
Average blood loss during normal spontaneous vaginal delivery (NSVD) estimated at 500 ext{ mL}.
Increased fibrinogen and decreased fibrinolysis lead to decreased postpartum hemorrhage (PPH).
Pulmonary System: “Squeeze” of delivery affects respiratory function.
Uterine Contractions Characteristics
Uterine Contractions Assessment:
Frequency: Measured from the beginning of one contraction to the beginning of the next.
Duration: Length of each contraction.
Intensity: Classified as mild, moderate, or strong.
Interval: Time period between contractions.
Effect of Contractions
Primigravida vs. Multigravida
Before Labor:
Primigravida: Complete effacement.
Multigravida: Early effacement and beginning dilation.
The 4 P's of Labor
Powers: Uterine contractions (strength and character).
Passenger: Fetal head characteristics such as diameter and molding of skull bones.
Passage: Maternal pelvis and soft tissues.
Psyche: Maternal psychological state during labor.
Fetal Characteristics During Labor
Fetal Head:
Diameter: Varies, impacts delivery.
Molding of Skull Bones: Allows adaptation to maternal pelvis.
Fetal Lie: Orientation of the fetus’s long axis to the mother (longitudinal, transverse).
Fetal Attitude: Position of the fetus's body parts in relation to one another (flexed, extended).
Presentation: Part of the fetus that first enters the birth canal.
Position: Refers to the direction the fetal back is facing.
Normal Labor Theories of Onset
Theories include the role of maternal hormones and fetal involvement, as well as physiological feedback loops.
Premonitory Signs of Labor:
Braxton Hicks contractions:
False labor that prepares the uterus.
Lightening: Descent of the fetus into the pelvic cavity.
Increased vaginal discharge leading up to the onset of labor.
“Bloody Show”: Mucus plug release mixed with blood.
Nesting: Increased energy and urge to prepare home.
Small weight loss may occur prior to labor.
Mechanisms of Labor: The 7 Cardinal Movements
Descent: The fetal presenting part moves through the pelvis.
Engagement: The widest diameter of the presenting part reaches the level of the ischial spines.
External Rotation: The fetal head rotates to align with the pelvis’s widest diameter.
Flexion: The fetal head nods forward, allowing the smallest diameter to pass through.
Internal Rotation: The fetal head reorients to fit the mother’s pelvic diameter.
Extension: The fetal head moves under the pubic symphysis to emerge from the vagina.
Expulsion: Delivery of the fetal body and shoulders.
Stages of Labor
First Stage:
Begins with the onset of true labor and ends with complete cervical dilation.
Divided into three phases:
Latent Phase: Onset of labor to 3-5 cm dilation.
Active Phase: Starts at 4-6 cm with rapid dilation.
Transition: Intense contractions occur; transition from 7-8 cm to complete dilation.
Second Stage:
Begins with complete dilation and ends with the birth of the baby. Urge to push felt here; crowning occurs.
Third Stage:
Begins with birth of the baby and ends with delivery of the placenta.
Signs of placental separation:
Uterus adopts a spherical shape.
Cord distends as the placenta detaches.
A gush of blood occurs as blood behind the placenta is released.
Fourth Stage:
Physical recovery for mother and baby; lasts from birth to 1-4 hours after delivery, with common occurrences like lochia rubra and perineal pain.
Patient-Centered Teaching: True vs. False Labor
False Labor:
Contractions inconsistent in frequency, duration, intensity.
Changes in activity do not alter contractions.
Discomfort felt in abdomen or groin, more annoying than painful.
Cervix shows no significant change after observation.
True Labor:
Consistent pattern of contractions increasing in frequency, duration, and intensity.
Activity often increases frequency and strength of contractions.
Pain begins in the lower back and sweeps to the abdomen.
Cervical changes marked by effacement and dilation.
When to Go to the Hospital or Birth Center
Guidelines for Admission:
Regular contractions occurring every 5 min (Nullipara) or 10 min (Multipara).
Ruptured membranes should be checked regardless of contractions.
Unexplained bleeding, especially bright red, should prompt immediate evaluation.
Decreased fetal movement should be reported to a healthcare provider.
Nursing Care in Labor and Delivery (L&D) Admission
Initial Priorities:
Establishing a therapeutic relationship with the patient and assessing both mother and fetus.
Focused Assessment:
Fetal Assessment:
Estimated gestational age (EGA), Leopold's maneuvers, fetal heart rate (FHR), and fetal movement.
Maternal Assessment:
Obtain personal information and history (e.g., prenatal care, Gs and Ps, prior delivery methods).
Assess any complications during the current pregnancy, including medications and allergies.
Physical Exam:
Head-to-toe examination with a focus on any signs of edema, scars, and fundal height.
Ongoing Assessment During Labor
Continuous monitoring of the fetus and maternal vital signs including:
Maternal Contractions:
Intensity and duration.
Fetal Monitoring:
FHR to assess fetal well-being throughout labor.
Pain Management Strategies:
Monitor for signs of need for pain relief (e.g., expressed need for medication).
Emergency Birth Guidelines
Key Nursing Priorities:
Minimize injury to the mother and baby.
Ensure maintenance of the infant's airway and temperature.
Upon delivery, the following protocols should be followed:
Locate the emergency delivery tray in preparation.
Remain with the patient, sending for help if needed.
Observe the infant’s color and respiration, using a bulb syringe if necessary.
Dry the infant, place skin-to-skin for immediate bonding, and cover them to maintain warmth.
Encourage suckling to aid uterine contractions postpartum.
Nursing Responsibilities During and After Birth
Preparation for Delivery: Setting up required medications and supplies; ensure proper antiseptic measures.
Immediate Care of the Infant: Ensure respiration is stable, assess for need for resuscitation, and perform APGAR scoring.
Maternal Care: Monitor vital signs, observe for postpartum bleeding, assess pain levels, and ensure proper uterine tone after birth.
Discomfort Relief: Apply ice packs for perineal discomfort and provide analgesics as needed.
Identification: Ensure proper identification bands for the infant are placed and that lochia is monitored for changes.
Chapter 18 - Pain Management for Childbirth
Unique Nature of Pain During Birth
Pain in childbirth encompasses physiological and psychological aspects.
Childbirth pain is normal; preparation enhances coping mechanisms,
Adverse effects of excessive pain:
Increased metabolic rate and demand for oxygen leading to decreased blood flow to the uterus and placenta.
Risk of hyperventilation and increased stress response affecting uterine contractions.
Variables Influencing Pain During Childbirth
Physiological Factors:
Visceral and somatic pain.
Tissue ischemia, cervical dilation, pressure on pelvic structures, and distention of vagina and perineum.
Psychological Factors:
Patient's cultural background, level of anxiety and fear, previous pain experiences, preparation for childbirth, and support system.
Pain Management Standards
Rights of patients to pain assessment and management.
Importance of ongoing education for both patients and families on pain management options.
Nonpharmacological Pain Management Techniques
Comfort measures such as effleurage, massage, hydrotherapy, and various breathing techniques are encouraged.
Importance of a supportive environment and education regarding childbirth is highlighted to reduce anxiety.
Pharmacological Pain Management Techniques
Awareness that drugs may have fetal effects (e.g., cardiovascular and respiratory changes).
Special considerations include the risk of interaction with maternal drugs and the administration timing affecting labor progression.
Regional Pain Management Techniques
Epidural Block: Commonly used method, but requires vigilance for potential adverse effects including maternal hypotension and urinary retention.
Combined Spinal-Epidural Analgesia: Provides rapid pain relief without loss of motor function.
Clinical Considerations for General Anesthesia
General anesthesia is reserved for cases where rapid delivery is necessary and can pose risks such as maternal aspiration and respiratory depression.
Preparation methods to minimize adverse effects include preoperative medications and careful monitoring of the patient.
Post-Anesthesia Care
Focus on assessing for return of sensation, monitoring vital signs, and ensuring adequate urinary output.
Nursing Process during Labor and Delivery
Thorough assessment and interventions tailored to the individual’s needs throughout the labor process, ensuring comfort and optimal care for both mother and baby.
Chapter 19 - Nursing Care During Obstetric Procedures
Amniotomy (Artificial Rupture of the Amniotic Sac)
Risks: Include potential for cord prolapse and infection.
Nursing considerations include obtaining baseline data and monitoring for complications.
Version (External or Internal Malpresentation)
Indications for version may include maternal conditions or complications with fetal positioning. Contraindications must be assessed prior to procedure.
Operative Delivery
Indications for operative delivery include maternal exhaustion or fetal distress. Risks associated include injury to both mother and child.
Induction/Augmentation of Labor
Indications may include fetal compromise or maternal conditions worsening with continuation of pregnancy. Contraindications to be aware of during nursing assessment.
Safety Alert for Tachysystole
Identify signs of tachysystole (contractions longer than 90-120 ext{s} or excessive frequency). Nursing actions should focus on timely response to ensure both maternal and fetal safety.
Cesarean Section
Indications include dystocia or fetal distress. A comprehensive approach to preoperative care and teaching is essential for optimal outcomes. Monitor for post-operative complications carefully, including assessing for infection and hemorrhage.