Labor and Delivery Practice Flashcards

Disclosure and Classroom Context

• Sensitive Topics Warning: The instructor issued a formal disclosure that labor and delivery topics can be highly sensitive and may trigger personal or mental traumas. Students are permitted to dismiss themselves if needed and discuss concerns with the instructor afterward.
• Visual Content: The lecture included two graphic videos: a vaginal birth and a cesarean birth. The instructor noted that LPN (Licensed Practical Nurse) students have a very slim to no chance of seeing these procedures in person during their roles, making the videos a primary exposure.
• Exam Information: The upcoming exam consists of $50$ questions, $30$ of which are taken directly from this specific lecture on labor and delivery.
• Practice Reality: The instructor noted that it is unlikely for LPNs to be hired directly into labor and delivery units, so the content was curated to be manageable for that specific professional scope.

Understanding Labor

• Definition of Labor: Labor is defined as the physiological process involving the body getting the cervix ready (part of human anatomy), moving the baby down the birth canal, delivering the baby, and ultimately delivering the placenta.
• Progress Factors: The progress of labor depends on three primary factors:   - Contractions: The frequency, duration, and intensity of uterine movements.   - Fetal Position: The orientation of the baby in the womb. The instructor noted the ideal position is face-down for delivery.   - Presentation Variants:     - Sunny Side Up: This is a term used to describe the baby facing upward (occiput posterior) rather than downward.     - Breech Presentation: This occurs when the baby is upside down (buttocks or feet first) compared to the ideal cephalic (head-down) position.
• Nursing Responsibility: Even though labor is a normal physiological process, nurses must continuously assess the mother and baby because clinical statuses can change rapidly.

True Labor versus False Labor

• True Labor Indicators:   - Cervical Change: True labor causes the cervix to open (dilation) and thin out (effacement).   - Contraction Pattern: Contractions get stronger and closer together over time, measured in minutes.   - Physical Activity: Contractions increase in intensity especially with walking.   - Bloody Show: This involves the expulsion of the mucus plug as it is pushed down; it can be observed or sometimes missed.
• False Labor Indicators:   - Cervical Stagnation: Contractions may be painful but do not result in thinning or opening of the cervix.   - Response to Intervention: Contractions often ease or stop with rest, hydration, or changes in position.
• Personal Anecdote: The instructor shared a story of being in true labor during clinicals, where she was timed at $6\,\text{minutes}$ apart. Her hospital turned her away because her effacement and dilation were not advanced enough despite her discomfort; she returned two hours later to be admitted.

The Four Stages of Labor

• Stage One: Cervical Dilation: Starts with the onset of true labor contractions and ends when the cervix is fully dilated to $10\,\text{centimeters}$. This is standardly the longest stage.
• Stage Two: Birth of the Infant: Spans from full dilation ($10\,\text{centimeters}$) to the actual birth of the baby.
• Stage Three: Birth of the Placenta: Occurs from the birth of the infant to the delivery of the placenta.
• Stage Four: Recovery and Stabilization: Focuses on the immediate postpartum period, ensuring both the mother and baby are stable.

Detailed Breakdown of Stage One Labor

• Nursing Priorities: Monitoring contractions, fetal heart rate (FHR), assessment of vital signs, pain management, assessing coping strategies, and determining if membranes have ruptured (water broken).
• Phases of Stage One:   - Latent Phase: Early labor where dilation is between $0$ and $3\,\text{centimeters}$. Generally manageable and things move steadily.   - Active Phase: Dilation is between $4$ and $7\,\text{centimeters}$. Contractions are stronger and more uncomfortable. The mother needs more support.   - Transition Phase: Dilation is between $8$ and $10\,\text{centimeters}$. This is the most intensive part. Symptoms include shaking, nausea, irritability, and the feeling of "I can't do it."
• Nursing Intervention (Active Phase): Nurses should encourage the client to ambulate (walk around) or change positions frequently to facilitate fetal descent and cervical dilation during the active stage.

Cervical Changes and Fetal Station

• Effacement: The process of the cervix thinning out. It is measured in percentages.   - $0\,$   - $100\,$
• Dilation: The process of the cervix opening up. It is measured in centimeters from $0$ to $10\,\text{centimeters}$.
• Fetal Station: A measurement (on a scale from negative to positive) of how far the baby has moved down into the pelvis relative to the ischial spine (anatomy landmark).   - Negative Numbers: The baby is still high up in the uterus.   - Zero Station: The baby's presenting part is at the level of the ischial spine.   - Positive Numbers: The baby has moved lower. A station of $+4$ means the baby is practically crowning and ready for delivery.

Assessing Contractions and Admissions

• Contraction Criteria:   - Frequency: Measured from the start of one contraction to the start of the next.   - Duration: Measured from the start of a contraction to the end of that same contraction.   - Intensity: How strong the contraction is.   - Resting Tone: The period of relaxation between contractions. This is critical because it allows for optimal oxygen flow to the baby.
• Admission Priorities: Safety assessments include vital signs, pain level, allergies, current medications, prenatal history, contraction pattern, vaginal bleeding, membrane status, and fetal heart rate (FHR).
• Membrane Rupture Documentation: When the "water breaks," nurses must document the Time, Color, Odor, and Amount.   - Clear fluid: Expected and normal.   - Green or Brown fluid: Indicates meconium (the baby's first bowel movement in utero).   - Foul Odor: Indicative of an infection.   - Immediate Action: Assess the FHR immediately after rupture and contact the provider if fluid is abnormal or smells bad.

Fetal Heart Rate (FHR) Monitoring

• Normal Baseline: Total range of $110$ to $160\,\text{beats per minute (bpm)}$.
• Abnormal findings: Late decelerations, bradycardia (low heart rate), tachycardia (high heart rate), or little-to-no variability must be reported immediately.
• Nursing Actions for Non-Reassuring FHR:   - Reposition the mother (moving her to her side).   - Increase IV fluids (per physician order).   - Stop Oxytocin if it is currently infusing.   - Assess maternal vital signs.   - Notify the RN or healthcare provider.   - Prepare for potential emergency interventions like a cesarean section.

Stage Two Nursing Care and Birth Sequence

• Physical Signs: Mothers may feel intense rectal pressure or the urge to have a bowel movement. This happens because the baby's head is moving past the ischial bone where the rectum is located.
• Crowning: The point where the head of the fetus is visible at the opening of the vaginal wall. This is accompanied by increased bloody show.
• Nursing Care During Pushing:   - Clean the perineal area.   - Help coach the mother through contractions.   - Prepare delivery supplies.
• Episiotomy: A surgical incision made to the perineum to enlarge the vaginal opening. It is not done routinely now.   - Nursing Role Post-Tear/Incision: Monitor for pain, bleeding, swelling, and signs of infection, and teach comfort care.
• Birth Sequence Steps:   1. Engagement: The initial movement where the fetal head enters the pelvis. This occurs before neck flexion.   2. Descent: The initial downward movement of the fetus into the pelvis. This also occurs before neck flexion.   3. Internal Rotation: Follows neck flexion; the fetus rotates its head to align with the pelvic outlet.   4. Extension: Occurs after internal rotation when the head crowns and extends to pass through the birth canal.

Stage Three: Delivery of the Placenta

• Timing: Usually occurs within $5\,\text{ to } 30\,\text{minutes}$ after the baby is born. If it takes longer than $45\,\text{minutes}$, intervention is needed.
• Signs of Placental Separation: A gush of blood, lengthening of the umbilical cord, and the uterus becoming firm and rising.
• Post-Delivery Oxytocin: Administered to help the uterus "clamp down" and prevent hemorrhage.
• Fundal Assessment Priority:   - Normal: A firm, midline fundus.   - Boggy Uterus: A soft uterus combined with heavy bleeding is a medical emergency.   - Maternal Distress/Hypotension: If the mother's blood pressure drops (e.g., from $125/80$ to $90/50$), slow the oxytocin infusion and notify the provider immediately.

Stage Four: Recovery and Postpartum

• Golden Hour: First few hours after birth focused on stabilization, bonding, and skin-to-skin contact (with both mothers and fathers).
• Assessment Focus (BUBBL): Fundus, lochia (vaginal discharge), vital signs, bladder status, and pain.
• The Full Bladder Issue: A full bladder can displace the uterus from the midline.   - If the fundus is deviated or boggy, the first nursing action is to have the mother void (urinate) and then reassess/massage the fundus to restore uterine tone and reduce bleeding risk.   - Attempting a void is preferred over a catheter to avoid infection or urinary retention risks.

Emotional Support and Education

• Teaching Strategy: Provide information in small, manageable pieces. Use simple words and remain calm and collected, as parents are often stressed or have forgotten previous Birthing knowledge.
• Analogies mentioned: The instructor mentioned a common (though graphic) analogy for the physical sensation of childbirth involved pulling one's bottom lip over the back of the head.
• Cultural Sensitivity: Nurses must respect cultural differences (e.g., using Vicks Vapor Rub as a traditional remedy or specific family dynamics).