Week 10: Labor and Delivery Methods

Overview of Labor and Delivery Process

  • Scenario Discussion:

    • Case Study: A client with a previous pregnancy history of an incompetent cervix underwent a cerclage procedure at 18 weeks. Now at 37 weeks, reports irregular contractions every 5-7 minutes.

      • Cerclage: a surgical procedure in which stitches are used to support the cervix, helping to prevent premature labor/miscarriage in women with a history of cervical insufficiency.

    • Nursing Response Options:

    • a. Advise going to the hospital to have cerclage removed to prevent cervical injury.

    • b. Suggest waiting until contractions are closer.

    • c. Acknowledge the client's anxiety for the baby.

    • d. Inform that a C-section is necessary while cerclage is in place.

Critical Thinking Application

  • Immediate Action Required:

    • The client should go to the hospital for evaluation.

  • Discussion Points:

    • Reasons for cerclage placement.

    • Patient discharge instructions to consider.

    • Patient education on signs/symptoms of preterm labor (PTL).

Preterm Labor (PTL)

Definition

  • Preterm Labor: Defined as uterine contractions and cervical changes occurring between 20 weeks and 36 weeks + 6 days of gestation.

    • Classification:

      • Moderately Preterm: 32-34 weeks.

      • Late Preterm/”Early Bird”: 34-36 weeks.

    • Complications for Pre-Term Labor:

      • Asthma risk due to respiratory structure and a lack of surfactant.

      • Cardiac issues may arise, including an increased likelihood of congenital heart defects and other cardiovascular complications.

      • Neurological risk of cerebral palsy.

      • Preterm infants may face gastrointestinal problems, such as necrotizing enterocolitis, which can lead to serious infections and complications.

      • Failure to thrive/sepsis risk.

Patient Education: When to Contact Healthcare Provider (HCP)

  • Acronym: PROM/PPROM.

    • Assessment Required if Water Breaks (COAT):

      • Color

        • Should be clear.

        • Brown or green: sign of meconium.

          • The child may be at an aspiration risk.

      • Odor

        • Should smell clean or bleachy.

        • If odorous, it can be a sign of infection.

      • Amount

        • A liter.

      • Time

        • Within 24 hours of breakage, you want to see the baby, or else the infant and mother are at risk of infection.

    • Symptoms of Concern:

      • Change or increase in vaginal discharge.

      • Pelvic or lower abdominal pressure.

      • Constant low-back pain.

      • Mild cramping.

      • Gush or trickling of water.

      • More than 4 contractions in 1 hour.

    • Important Note: Signs of infection must be considered!

Risk Factors for Preterm Labor

  • Common Risk Factors:

    • Infections (UTI, HIV, active HSV/herpes, chorioamnionitis).

    • Previous preterm births.

    • Multifetal pregnancies.

    • Substance use (smoking, drugs).

    • History of abuse.

      • More prone to domestic abuse.

    • Lack of prenatal care.

    • Uterine abnormalities.

    • Low pre-pregnancy weight.

Medications Used for Preterm Labor

  • Medication Administration Principle: The 5 Rights - Right Patient, Drug, Dose, Route, Time.

  • Medications Include:

    • Nifedipine: A Calcium channel blocker that suppresses contractions by inhibiting calcium from entering smooth muscle.

      • Caution: Do not administer with magnesium sulfate or beta-adrenergic agonists.

    • Magnesium Sulfate: A commonly used tocolytic that depresses the central nervous system (CNS) and relaxes smooth muscle to inhibit uterine activity.

      • Important Note: Antidote is 10% Calcium Gluconate.

      • Also used for preclampsia.

    • Terbutaline: A beta-adrenergic agonist that relaxes smooth muscle and inhibits uterine activity (“Turbulence delays arrival time”).

      • Dosage Information: 0.25 SQ.

      • Monitoring: Observe cardiac output.

    • Indomethacin: NSAID that suppresses preterm labor by blocking prostaglandin production, particularly effective under 32 weeks of gestation.

      • Enhances fetal-lung maturity.

    • Betamethasone: Glucocorticoid administered IM in two injections 24 hours apart; enhances fetal lung maturity.

Labor and Delivery Processes

Intrapartum Nursing Care

  • Key Clients:

    • The fetus

    • The birthing parent

    • The family unit

Understanding Labor Pain

  • Labor Pain Characteristics:

    • Purposeful: Has a reason related to childbirth.

    • Anticipated: Expected during the birthing process.

    • Intermittent: Occurs in patterns rather than continuously.

    • Normal: Common part of childbirth.

Pain Locations During Labor

  • Stages of Pain:

    • Early labor stage pain can vary in intensity and location.

      • Radiating from the back to the hips.

    • The delivery stage involves somatic and visceral pain.

    • Releases endorphin when experiencing pain.

Psychological Responses: Fear-Tension-Pain Cycle

  • Cycle Description:

    • Fear results in tension.

      • The body won’t relax enough to deliver, thus creating more pain.

      • Comforting environments and support aid in labor delivery, increasing oxytocin levels, which help with uterine contractions and promote a more effective birthing process.

    • Tension can amplify pain perception.

    • Tension in areas (jaw, pelvic floor, legs) reduces oxygen to the uterus, thus affecting labor.

The Gate Control Theory of Pain

  • Theory Explanation:

    • Other sensations can block pain sensations from reaching the brain, suggesting that pleasure or various stimuli can alleviate pain during labor.

      • Warm compressions, rice sock, or cold wash clothes on pressure points.

The 5 P's of Labor

Overview

  • Essential Components:

    • Passageway

    • Passenger

    • Powers

    • Position

    • Psyche

5 P's Detailed

  • Passageway: Refers to the pelvis (the “birth canal”), the main passage for birth.

    • Negative movement means they're moving down the canal.

    • Zero at the inlit.

    • Positive movement when exiting mom, +4 hit the floor!

    • Arrest of labor/sephlow pelvis disproportion may result in the mom needing a C-section due to the inability to deliver it through the canal.

    • The gyneoid shape of the pelvis is PERFECT for delivery (seen in 51% of women).

  • Passenger: Concerns the fetus, the baby traveling through the passageway.

    • Presentation: The part of the fetus entering the pelvic inlet first.

    • Fetal Lie: Orientation of the fetus to the maternal spine (longitudinal or transverse).

    • Breech: When the buttocks or feet of the fetus present first at the pelvic inlet, this may complicate the delivery process and often necessitates special care or interventions (C-section delivery to lower the risk).

    • Transverse: When the fetus is positioned horizontally across the uterus, which can hinder the progress of labor and typically requires medical intervention to facilitate a safe delivery (C-section delivery to lower the risk).

    • Vertex: This is the most common presentation, where the fetus is positioned head down, allowing for a more straightforward delivery process.

      • Complete flexion: ideal, chin to the chest.

      • Moderate flexion

      • Poor flexion: head is backwards

      • Hyperextension: more difficult delivery.

    • Occipital Posterior: In this position, the fetus is facing the mother's abdomen, which can lead to a longer labor and increased discomfort for the mother; assistance may be required to help reposition the baby or facilitate delivery.

      • Causes back pain, have the client lean against a wall or partner during contractions to alleviate some pressure and provide support.

      • During delivery, give the mother a ball or have her on all 4s.

  • Powers: Refers to uterine contractions, the driving force of labor.

    • Effacement: The thinning and shortening of the cervix during labor, which allows it to open and facilitates the descent of the baby.

    • Dilation: The process in which the cervix opens to allow the baby to pass through the birth canal, measured in centimeters from 0 to 10.

  • Position: Maternal positioning that enhances gravity and aids fetal descent.

    • Hand and knees: helps with back pain.

    • Movement: helps with pain, swaying, rocking, and helps to relaxes.

      • Contraindicated if the client has an epidural.

  • Psyche: Psychological readiness, including maternal stress and support factors.

    • Water immersion: Provides buoyancy and can ease labor discomfort, promoting relaxation and a sense of privacy.

    • Doula: A trained professional who provides continuous physical, emotional, and informational support to the mother before, during, and shortly after childbirth, helping to enhance the birth experience.

    • The body is making room and space for the baby to deliver.

Cardinal Movements of Labor

Overview

  • Movements During Labor:

    1. Engagement

    2. Descent

    3. Flexion

    4. Internal Rotation

    5. Extension

    6. External Rotation

    7. Expulsion

  • Done to adapt to the pelvis for delivery.

Descriptions of Each Movement

  • Engagement: Fetal head passes through the pelvic inlet.

  • Descent: Fetus moving down within the pelvis.

  • Flexion: Chin to chest to allow easier passage through the pelvis.

  • Internal Rotation: The presenting part rotates to align with the maternal pelvis.

    • Done to move against mom’s back.

  • Extension: The fetal head emerges from the vagina.

  • External Rotation: The fetal head rotates to align with the shoulders after delivery.

    • When the head reaches the perineum.

  • Expulsion: Delivery of the rest of the body post-head delivery.

    • Shoulder slips under the pelvic bone.

Uterine Contractions

Characteristics

  • Components of Contractions:

    • Increment, Peak (Acme), Intensity, Duration, Decrement, Interval (rest period), Frequency

    • 5 contractions, which are 1 minute, have occurred within an hour.

Cervical Effacement and Dilation

  • Effacement: Thinning of the cervix expressed as a percentage (0 to 100%).

  • Dilation: Opening of the cervix measured in centimeters (0 to 10 cm).

Labor Stages

Stages Overview

  • Stage One: Cervical thinning and dilation.

  • Stage Two: Pushing and birth.

  • Stage Three: Delivery of the placenta.

  • Stage Four: Recovery and breastfeeding.

  • External Fetal Monitor use during labor: This device allows healthcare providers to continuously assess the fetal heart rate and the strength of contractions, ensuring the baby's well-being during the labor process.

    • Determines the position and presentation of the baby.

    • Goal: To ensure that both the mother and baby remain stable throughout labor and to identify any potential complications early on.

  • Internal Fetal Monitor use during labor: This device provides a more accurate and direct measurement of the fetal heart rate and uterine contractions by being attached to the baby's scalp, which can be helpful when external monitoring is inadequate.

    • It is typically indicated for high-risk pregnancies where closer monitoring is necessary to ensure the safety of both mother and child.

    • Mom has to be at least 2 cm dilated, and their water bag has to be broken.

Active Labor Description

  • Stages of Active Labor:

    • Latent (Early) Labor: Lasts up to 12 hours with contractions 30-60 seconds apart. Begins effacement and dilation. Expected signs include mucous discharge and potential water break.

      • Dilation: 0-6 cm.

      • Tips: Stay at home, rest, take a short walk, or do light activities.

      • Contractions: 30-45 seconds each, 5-30 minutes apart.

    • Active Labor: Lasts about 6 hours; contractions become stronger and more frequent. Dilation progresses up to 8 cm.

      • Dilation: 6-8 cm.

      • Tips: Actively try getting to the hospital, use different positions, breathing exercises, and relaxation techniques.

      • Contractions: 45-60 seconds each, 3-5 minutes apart.

    • Transition Stage: Lasts a few minutes to hours, the most intense phase, contractions are very strong. Dilation reaches 10 cm.

      • Dilation: 8-10 cm.

      • Tips: May feel nauseous or shaky, support people needed to provide focus.

      • Contractions: 60-90 seconds each, 3-5 minutes apart.

Pain Management During Labor

Non-Pharmacological Techniques

  • Techniques:

    • Sensory stimulation (aroma, music, lighting).

    • Cutaneous strategies (massage, position changes).

    • Continuous labor support.

    • Hydrotherapy (showering) and ambulation.

    • Focused breathing techniques.

    • Effleurage is a circular massage for the abdomen.

Pharmacological Pain Relief

Pain Management Options

  • Medications Include:

    • Sedatives for early labor (ex, barbiturates).

    • Opioids administered via IV or IM (ex, fentanyl).

    • Regional anesthesia options (epidural and spinal analgesia).

    • Types of analgesics administered must be monitored for fetal safety.

Epidural Anesthesia

  • Epidural Instructions:

    • Informed consent needed.

      • Education: Maternal hypotension is the biggest concern!!

      • Monitor for maternal vital signs and fetal heart rate frequently throughout the procedure to ensure safety and prompt intervention if necessary.

        • Other side effects: Loss of spinal fluid can cause headache, N/V, itching, and high block (can’t breathe). 

    • Assess fetal heart rate before administration.

    • Empty the bladder. 

    • Administration by an anesthesiologist or nurse anesthetist.

    • Positions must be held for effective placement.

General Anesthesia

  • Use Guidelines:

    • Reserved for emergencies due to significant risks, including respiratory depression in the neonate.

    • Essential preparations involve antacid administration and rapid delivery protocols to minimize fetal exposure.

Conclusion

  • Goal: To achieve a happy, healthy birth parent and baby!