Labor and Delivery Notes

Exam 3 Review

  • Exam average was 86, which is considered good for this exam.

  • Exam 3 will cover the second PowerPoint for Unit 6 (antepartum complications/pregnancy complications) and the two PowerPoints under Unit 7.

  • Unit 6 is split between Exam 2 and Exam 3.

Nursing Measures to Improve Fetal Heart Rate

  • Goal: Review fetal heart rate patterns to determine fetal well-being.

  • Interventions:

    • Turn the mother on her side (left side optimal, but right side if needed).

    • Administer oxygen at a high dose (8-10 liters) via mask, not nasal cannula, to increase oxygen perfusion across the placenta to the fetus.

    • Discontinue oxytocin/Pitocin (synthetic oxytocin) if running, as contractions stress the fetus by clamping off the uterine spiral arteries.

    • Increase IV flow rate to improve perfusion across the placenta.

    • Amnioinfusion for variable decelerations:

      • Use an intrauterine pressure catheter placed by the physician.

      • Instill IV fluid (saline) into the fetal environment to cushion the umbilical cord.

      • Rationale: Variable decelerations are caused by cord compression; amnioinfusion relieves pressure on the cord.

    • Expedited delivery (C-section or vaginal) if necessary.

Understanding Amnioinfusion

  • Amnioinfusion is only for variable decelerations.

  • Amnioinfusion Procedure:

    • An intrauterine pressure catheter will be placed behind the baby’s head in the uterus by a physician.

    • Connect the catheter to IV tubing and IV fluid, and instill the fluid into the fetal environment.

    • Amnioinfusion gives a cushion, the bubble wrap around the umbilical cord.

Labor and Delivery: Key Concepts

  • Analgesics: Administered through IV, can cause queasiness.

  • Manual dilation: Doctor manually dilated patient to 5 centimeters.

  • Non-progress Labor: Labor was not progressing.

  • The five one one Rule When to come to the hospital:

    • Contractions are five minutes apart (frequency).

    • Last for one minute (duration).

    • Pattern occurs for one hour.

  • Membrane Rupture: Come to the hospital as soon as membranes rupture.

Nursing Care of the Labor Patient

  • Establish Rapport

    • Recognize the significance of the day for the woman and her family.

    • Positive rapport impacts the patient's birth experience.

  • Assess Patient and Fetus Well-being

    • History: Due date, previous labor experiences, primip/multip status.

    • Current labor history: When contractions started, membrane status.

    • Risk for hemorrhage.

    • Patient concerns and birth plan.

  • Determine if Patient is in Labor

    • Contraction pattern (5-1-1 rule).

    • Cervical check (dilation and change over time).

    • Contraindication: Placenta Previa.

  • Membrane Rupture Assessment

    • If suspected, patient should go to L&D immediately.

    • Rupture can range from trickle to gush.

    • Risk of bacterial infection in the uterus.

  • Testing for Membrane Rupture:

    • Nitrazine paper test: vaginal exam, run the paper between fingers, blue color indicates rupture.

    • Speculum exam: Q-tip sample of fluid near the cervix, look at the slide under the microscope where amniotic fluid creates a ferning-type pattern.

  • Monitor Mom and Baby

    • Mom's vital signs hourly (every 15 minutes with epidural).

    • Fetal monitoring to assess fetal tolerance of labor.

    • Periodic vaginal exams to assess cervical dilation and fetal head descent (station).

  • Assess Discharge

    • Amniotic fluid, blood, or mucus.

    • Bloody show: Blood-tinged vaginal mucus which means cervix is rapidly changing or dilating.

    • Frank red bleeding: suspecting placental problems like abruption placenta.

    • Spontaneous rupture of membranes (SROM): Assess color and fetal heart rate immediately; meconium can be present.

Meconium-Stained Amniotic Fluid

  • Meconium is caused by fetal stress, resulting in relaxation of the anal sphincter.

  • If present, take extra precautions to prevent aspiration by the baby.

  • After delivery, suction the airway well.

  • Some facilities/providers may visualize the cords before the first breath is taken.

Maintaining Hydration During Labor

  • IV fluids are preferred.

  • Ice chips and popsicles are commonly allowed.

  • Rationale: To avoid a full stomach in case a C-section is needed.

Nausea and Vomiting in Labor

  • Common, especially around 4 cm and 10 cm dilation.

  • Cervical checks are performed when vomiting is suspected to happen around 10cm dilation.

Bladder Management

  • A full bladder can impede fetal head descent.

  • Encourage patients to empty their bladder every 1-2 hours.

  • If an epidural is in place, use a Foley catheter.

Comfort Measures

  • Position changes.

  • Room temperature control.

  • Pain relief measures.

  • Perineal hygiene.

  • Cool washcloths.

  • Music.

  • Emotional support, encouragement, and education for their birth plan.

Delivery Preparation

  • Ensure the delivery table is set up.

  • Call appropriate personnel (doctor) in time.

  • During stage two, the pushing stage, the nurse stays at the patient's side the whole time the patient is pushing, which can last for hours.

  • Don't leave a patient unattended who is pushing.

  • Let the doctor know if you see a head.

  • As soon as the placenta is delivered, the nurse is going to give pitocin.

  • The nurse is Watching for the signs that the placenta is ready to be delivered.

Postpartum Care (Immediate)

  • Clean the patient and ensure perineum is dry.

  • Check vital signs, fundal height, and fundus.

  • Massage the fundus with one hand above the pubic bone and the other at the top of the uterus, making sure that the uterus doesn't invert or turn inside out as we're massaging it.

  • Massage the fundus firmly.

  • The priority is to make sure that they're not hemorrhaging. Everything else can wait until that is confirmed.

  • Observe lochia (vaginal bleeding).

  • Assist in breastfeeding if planned.

  • Provide comfort measures.

  • Take pictures.

Objective 11: Common Complications During Labor and Delivery

  • Dystocia: Dysfunctional or abnormal labor.

Passageway Complications

  • Ideal pelvis shape is gynecoid; other shapes may impede fetal passage.

  • Cephalopelvic disproportion (CPD): Fetal head and maternal pelvis are not proportional.

    • Caused by small pelvis and/or large fetus.

    • Results in failure to progress, potentially leading to C-section.

    • The pressure of the pressure of the fetal head on that cervix pushing through the cervix causes dilation.

Passenger Complications

  • Fetal malposition: E.g., occiput posterior (OP).

    • Fetus face up.

    • Causes back labor and slows labor progress.

    • Frequent position changes can help.

  • Fetal malpresentation: Anything other than vertex (head-down) presentation is the goal.

    • Ideal presentation is the vertex, what you see emerging when the head is occiput anterior.

    • Shoulder presentation (transverse lie) requires C-section.

    • Breech presentation: Consider external version to flip the baby.
      External Version
      *Medications are given to relax the uterus.
      *Manually flip the baby to be head down.

Breech Presentation

  • Breech Types:

    • Frank breech: Feet are up by the ears.

    • Footing breech: Feet are coming down with the buttocks.

  • Breech babies will lay with their toes by ears after delivery.

Why We Don't Deliver Breech Babies Vaginally

  • If Twin A is Head Down and Twin B is Feet down they will deliver Twin B vaginally.

  • High risk of fetal injury due to lack of head molding.

  • Risk of cervical closure around the fetal neck which can be fatal.

Intervention for Breech Positioning upon Delivery

  • With any provider who does vaginal breech delivery, they will reach their hand inside of the uterus, find the face, put their finger in the mouth, and force the chin to tuck, which diminishes the risk of cervical closure.

Managing Twin Deliveries

  • Twin A (first to emerge) is cephalic; Twin B is breech may be delivered vaginally.

  • Higher-order multiple pregnancies usually delivered by C-section.

Question: Occiput Posterior

  • After a vaginal exam, the nurse notes that the fetus is in the Occiput Posterior position. The Nurse anticipates the woman will have intense back pain.

  • Because the back of the fetal head is in the low back.

PROM (Premature Rupture Of Membranes)

  • Is when the membranes rupture before labor starts.

  • Increased risk of infection.

Definition of PROM

  • Spontaneous rupture of the amniotic sac before labor but after the mom has reached full term (37 weeks or more).

PPROM (Preterm Premature Rupture Of Membranes)

  • A preterm membrane rupture before reaching 37 weeks.

    • Increase the risk of infection: Chorioamnionitis.- inflammation of the chorionic and amniotic membranes and fluid.
      Symptoms: Maternal fever and fetal tachycardia.
      *Can cause maternal sepsis and fetal sepsis.
      *Antibiotics can be given to prevent or decrease the risk of infection before delivery.

  • Labor will be induced once infection becomes dangerous.

Powers - Contractions

  • *Hypotonic- Inadequate contractions.
    *Too short
    *Not intense enough
    *Not frequent enough

    *That can be fixed with augmenting the labor either with a amniotomy or giving oxytocin.

  • *Hypertonic- Contractions are coming to quickly.

Precipitous Labor

  • Labor that lasts less than three hours.

  • It does increase the risk for birth trauma, and or bruising.

Nursing Alert: Rapid Progress

  • Always listen to mom.

  • Iff she feels like something's happening, we respect her, and we investigate.

  • If the baby's coming quickly, encourage the mom to breathe so she doesn't push. (panting).

  • Precipitous delivery is any delivery that is not attended by the doctor or nurse midwife; this can cause a patient to deliver the baby by themselves.

Methods of Inducing Labor

  • *Indications for Medical Induction
    Any type of emergency that threatens the life or well-being of the patient or the baby.
    *Post-term Pregnancy/New Med Condition.
    *A pregnancy beyond 41 to 42 weeks gestation.
    *The placenta ages with Calcium deposits- cause uro-placental insufficiency.
    *Increased risk of perinatal mortality, oligohydramnios, and meconium-stained amniotic fluid(R/T Bowels Filled with Meconium).
    **Macrosomia- Large Baby.

Bishop Score

  • Test to determine how ripe the cervix is.

  • The higher the score, the more ripe the cervix is.
    Example: Given the Bishop Scors of 3,5,7,9. The higher Number (9) has the best chance of a successful delivery because it is the most ripe.

Cervical Ripening Methods

Either Mechanical or Pharmacological.If Bishop Score is low, we need to ripen the cervix before we start an induction.
*Ripening the cervix means getting it to soften up and start effacing or thinning out and dilating a little bit.

Mechanical

*Stripping the Membranes- vigorous and releasing prostaglandins.
*Catheter Balloon- The balloon can be inserted, inflated, and apply traction to kind of pull it down, so that helps it to ripen mechanically.

Pharmacological- to give a prostaglandin called Cervadil
*A tablet that is divided in quarters and apply it next to the cervix
that causes it to ripen.

Amniotomy

  • A artificial rupture membranes (ARAM)

  • Releases Prostaglandins removes the cushion in front of the cervix.

    • The the fetal head must be engaged prior to rupturing the membranes to avoid cord prolapse.

    • Check fetal heart rate.

Giving IV Pitocin

*Goal: For contractions to last 60 to 90 seconds with a frequency of every 2 to 3 minutes.
*Making sure we don't hyperstimulate the Pitocin because it can lead to Major Lawsuits.

  • Hypertonic Contractions: More than 5 contractions in 10 min

  • Frequency: Two Minutes Apart: Total 5 contractions in 10 mins
    Note: Given After Placenta is Delivered; if inducing start small and increase slowly.
    *Pitocin is best to use when augmenting already naturally contractions.

Clinical Practice. Thea is 37 Prima Gravada - She Presents in L&D for induction

  • What are some Indications for Induction?
    *Overdue/Large Baby.
    *Is the most likely Complication? Large Baby+ Cephalopelvic Disproportion.
    Bishop Score of 7. What does the tell you? The cervix is ripe.

Scenario Analysis

  • Started IV Pitocin. What will you be watching for? Hyperstimulation.

    • And from which event would you stop the KETOSIS?

      • If we have more than five contractions.

  • After four hours on PIT, the fetal head is engaged. What is now an option? Rupture The Membrane.
    *Because The Head is Engaged- Preventing Prolapse.

  • The provider ruptures the membranes. What do you teach Thea about the benefits and the risks of rupturing the membrane?
    *
    Benefits: Releases Prostaglandins and gets rid of that cushion in front of the fetal head.
    *
    Risks: Infection/ and cord prolapse if the head is not engaged.

Objective 12: Prematurity

Delivery between to 20- 37 weeks Gestation.The Lungs are the last body system to mature, which is the biggest risk with prematurity.
*Steroids can be prescribed to promote blood maturity/
*Progesterone can be prescribed to a patient with increased risk for preterm labor during pregnancy.

  • And then if contractions do start prematurely, we can stop it with a smooth muscle relaxant because the uterus is a smooth muscle.

Magnesium Sulfate. is can be given for two indications, either for preeclampsia or for to stop contractions.
S/S:

  • We check for symptomatic toxicity by checking the reflexes and watching for decreased respirations, but the way to promote long maturity, we give corticosteroids such as beta method cell. *
    *Give it to the Mom- Not the BABY.

Preterm Prom - (PPOM)

  • Membranes rupture before the baby reaches term.
    This is very concerning because we want to get the baby delivered before infection.

  • Priority Assesment: Watching for S/S of Infection.

Scenario

Preterm Problem and Infection is Present.
Give Antibiotics and Felicitate the Delivery.Because they will be safer on the outside.
Infection Not Present, Hospitalized on bed rest and Fetal Monitoring./ Monitor Signs of Infection. Pelvic Rest.
*Give Prophylactic Antibiotic Therapy. Tocolytics and steroid therapy to promote lung maturation.

Preterm Labor

Leading cause of infant death. We can tell the patient the signs and symptoms of preterm labor. Uterine Contractions.

  • They will not perceive they'll be having contractions but won't recognize it.
    S/S:
    Back Ache
    Pelvic Pressure.
    Vaginal Bleeding.
    Nausea/Vomiting/Diarrhea/Cramping.

Cervical Change

The Fenofibronectin Test* - if Positive - it indicate that the patient getting close to delivering their baby permanently.
*If it comes back Negative for Fetal Fibronectin, Delivery is not Likely to occur within to 2 weeks.
Tocolytics/ Steriod Therapy.

How to Minimize Risk

Quit Smoking - Avoiding STI infections. Give Progesterone+ pelvic Rest- Hydration - Teach patients how to recognize contractions and count them and letting the doctor know if they are having contractions. We can monitor from a distance.

Birth Emergencies

*Any Type of Emergency that Causes Fetal Distress. Such as Ominous FHR Pattern. Late Decels, Proglonged and Persistent. Lack of variability and Bradycardia.
*Collapsed Cord- Fetal Lifeline Membranes Ruptured Fetal Heart Rate Drops, Because Head Isn't Engaged And Allowing Cord to Come Down.
The Priority Assessment is to put the patient in the new chest position, use gravity to pull the head away from the pelvis.

  • Put Your hand in the vagina, push against head - keep hand while running to the delivery room, cut. *
    The treatment from a prolapsed cord is for her to push the head off the cord because if it doesn't, the heart can cut off circulation to the and is gonna die in the time it took to get the baby out.

Shoulder Dystocia:

Shoulders get stuck, usually due to macrosomia(Big Baby), Baby Has to come out within 2 Mins of the Head Being Delivered. This a life-Threatening Emergency, it cant get, ideally, the baby should come out within 2 mins of when the head being delivered, and the that is a life-and-death Fire Hazard.
*Mc Roberts Maneuver: Hyper flex+ push the knee to the Mom's Chest.
*Suprapubic Pressure.
*Pushing on the shoulder to collapse the shoulder, or The Doctor can Reach in with his Fingers Pull Out First.

Uterine Rupture

A tearing of the uterus, fetus the starts to fall out the of the uterus instead of out the pelvis, not good FHR pattern and maternal shock, Emergency situation, If Detected, Emergency C-Section to save Life of both Mom and Fetus.
Placenta abnormalities can be reviewed through previous lectures.
*Ambilibal Cord Abnormalities+ around the Neck as often as a quarter of the time
**True Knots - Swam a Loop, Pulled until Knotted (1-5 % deliveries, tolerate Fine).

Maternal Crises

  • If eclampsia, HELLP Syndrome, DIC all require and Emergent C-Sections.

Assisted Deliveries:

*Vacume- Suction cup is put on the fetal head and pulling and can create Swollen head/Bruise which can lead to hyper bilirubin
*Forceps- Salad Tongs, that that Eases the Baby up.

Cesarean Birth.

The seven Layers have to Cut Through+ the baby is still not guaranteed.

S/S:
Neonatal Risks( Doesn't Get Squeezed)
Needs a Pediatrician.

Prior to the cut an IV and caths need to be placed. Ensure emotional support, be watching vital signs, and urine output.
*C section Delivery- Light Lokia.
Make sure the mom has an IV and Foley and is at peace.

Scenario Analysis: 33 weeks pregnant presented w/ fluid trickling

*Suspect: Amniotic Fluid + 33 Weeks Along, ovaries are ruptured, priority infection.

Infection Not Present.
Give Prophylactic Antibiotic Therapy+ Progesterone/ Prevent Contractions, Keep Monitor after 36 Hrs, She spikes a Fever and Has An Elevated WBC and the fetal Heart rate baseline is 180 -160 is the Base Line, now we have chorioamnionitisTHE NEW IS IS TO GET THAT BABY OUT- CUTE BABY!