chapter 16 Prof J

Chapter 16 - Labor and Delivery

Delivery Venue Options

Hospitals:
- Most births occur in hospitals.
- Provide access to key personnel, essential equipment, pain control options, and emergency services.
Home births:
- Many opt for home births due to negative experiences with hospitals.
- Patients may feel more comfortable, empowered, and in control at home.
Birthing centers:
  - Generally freestanding locations not integrated within hospitals.
  - Most births are attended by midwives.
  - Cater to patients with low-risk pregnancies.
  - Have transfer agreements with local hospitals for emergencies.

Five Ps of Labor

Labor comprises five essential components known as the five Ps.
  - Dysfunction in any component may lead to complications that necessitate intervention.
  - The five Ps include:
    - Power:
      - Relates to uterine contractions and maternal pushing efforts.
    - Passageway:
      - Refers to the anatomical structures of the patient’s pelvis and soft tissues.
    - Passenger:
      - Pertains to the fetus being delivered.
    - Psyche:
      - Concerns the mental state of the patient during labor.
    - Position:
      - Refers to the position of the patient during labor.

Five Ps of Labor: Power

Primary Powers:
- Involuntary uterine contractions.
- Occur in the upper two-thirds of the uterus, exerting pressure on the fetus which facilitates cervical dilation and effacement.
Secondary Powers:
- Voluntary maternal pushing efforts after the cervix has fully dilated.
- Effective pushing aligns with contractions and may require facilitation from nursing staff.
Contraction characteristics:
- Frequency, duration, and intensity are influential to labor power.
Augmentation:
- Administration of Oxytocin can enhance the strength of contractions.

Five Ps of Labor: Passageway

The structure of the pelvis:
- Gynecoid pelvis shape:
- Provides the most favorable passageway for delivery.
Soft Tissue Ability:
- Soft tissues usually do not obstruct fetal passage except when there is scar tissue from gynecological surgeries.
Pelvic Floor Muscles:
- Assist in turning and orienting the fetus during the cardinal movements of delivery.

Five Ps of Labor: Passenger

Significant factors regarding the fetus and labor include the following:
  - Fetal head size
    - The largest part of the fetus, crucial for safe passage.
  - Fetal Presentation:
    - Refers to the part of the fetus entering the pelvis first, typically the head (cephalic presentation).
    - Breech Presentation:
      - Occurs when the fetus presents with buttocks or feet first.
  - Fetal Attitude:
    - The relationship of the fetal parts to one another.
  - Fetal Lie:
    - Orientation of the fetus in relation to the maternal spinal column (e.g., cephalic, transverse).

Five Ps of Labor: Psyche

The mental state of the patient impacts labor progression.
  - Factors that can hinder labor include:
    - Anxiety
    - Stress
    - Fear
    - Pain tolerance
Conversely, relaxation can facilitate labor progress.

Five Ps of Labor: Position

Effective contraction tends to occur when the patient is upright.
  - Gravity aids successful labor and delivery.
  - Optimal pelvis angles for birth occur with sharply flexed hips, similar to a squatting position.
  - Movement into comfortable positions typically correlates with better labor outcomes.
  - Lithotomy Position:
    - A position often utilized during birth, although its evolution is thought to favor the provider's ease rather than optimal maternal positioning.

Signs of Labor

Mechanisms triggering labor remain largely unclear and encompass multiple factors.
Signs indicating impending labor include:
  - Regular contractions
  - Presence of bloody show
  - Lightening:
    - Fetal descent into the birth canal, commonly observed two weeks prior for primigravida patients.
  - Nesting impulses
  - Gastrointestinal distress (such as heartburn, nausea, diarrhea)
  - Antepartum weight loss of 1 to 3 lb prior to labor onset
True labor is confirmed through cervical changes (dilation and effacement).

Stages and Phases of Labor

There are four stages of labor:
  - First Stage:
    - Involves dilation and effacement of the cervix.
    - Latent Phase:
      - Dilation from 0 to 6 cm.
    - Active Phase:
      - Dilation from 6 to 10 cm.
    - Transition Phase:
      - Dilation from 8 to 10 cm.
  - Second Stage:
    - Commences pushing and concludes with the baby’s birth.
  - Third Stage:
    - Begins with the baby's birth and ends with the delivery of the placenta.
  - Fourth Stage:
    - Initiates after the delivery of the placenta and concludes when the patient stabilizes, generally within 4 hours.

Stages and Phases of Labor: First Stage

Latent Phase Characteristics:
- Prolonged and characterized by excitement; contractions resemble mild menstrual cramps and are mild upon palpation.
Active Phase Characteristics:
- Increased focus and potential anxiety of the patient; more regular and painful contractions that are moderately strong upon palpation.
Transition Phase Characteristics:
- Strong contractions occurring close together; patients may exhibit agitation and irritability, representing the shortest phase of labor.

Stages and Phases of Labor: Second Stage

Pushing:
- May be postponed until the patient experiences the urge to push.
- Duration varies from 20 minutes to 2 hours.
Cardinal Movements during Fetal Descent:
  - Engagement:
    - Fetal head reaches the level of the ischial spines.
  - Descent:
    - Fetus moves past the ischial spines.
  - Flexion:
    - Fetal chin approximates the chest under maternal tissue pressure.
  - Internal Rotation:
    - Fetal head rotates in the birth canal.
  - Extension:
    - Position transition from flexion as the head emerges.
  - External Rotation (Restitution):
    - Fetal head completes rotation as shoulders maneuver for delivery.
  - Expulsion:
    - The body of the fetus is delivered.

Stages and Phases of Labor: Third Stage

Duration typically ranges from approximately 5 to 30 minutes.
Uterine contractions facilitate placenta delivery.
Continual post-delivery contractions help to occlude blood vessels in the decidua, preventing maternal hemorrhage.
Uterine Atony:
- A failure to contract effectively, leading to potential postpartum hemorrhage.

Stages and Phases of Labor: Fourth Stage

During this stage, monitoring involves:
  - Uterine position, vaginal bleeding (lochial assessment), and vital sign monitoring.
  - Administering pain medications as necessary.
  - Facilitating skin-to-skin contact and the initiation of breastfeeding for the newborn.

Nursing Care During Labor

Responsibilities based on place of birth may involve:
  - Initiating an IV line (typically 18 gauge).
  - Collecting blood and urine samples for laboratory analysis.
  - Monitoring of vital signs.
  - Providing continuous or intermittent fetal monitoring.
  - Encouraging urination every two hours for the laboring patient.
  - Assessing labor progress.
  - Offering labor support.
  - Educating the patient as needed.
  - Administering pain relief.

Fetal Monitoring

Purpose:
- Assessment of the fetal heart rate (FHR) for patterns that may indicate fetal distress.
Normal Patterns:
- Associated with positive neonatal outcomes.
Abnormal Patterns:
- Denote potential hypoxemia and risk of hypoxia.
Monitoring Frequency:
- Intermittent auscultation generally occurs every 15 to 30 minutes during the active labor phase and every 5 to 15 minutes in the second stage.
- Continuous fetal monitoring is standard in the U.S., where nurses evaluate FHR every 30 minutes in low-risk first stages and every 15 minutes in second stages, with increased frequency for high-risk cases.

Fetal Monitoring: Characteristics

Baseline Heart Rate:
- Assessed over 2 minutes within a 10-minute span, with the normal rate being between 110 and 160 bpm.
Variability:
- Refers to irregular fluctuations in FHR; moderate variability is defined as an amplitude of 6 to 25 bpm over 10 minutes.
Accelerations:
- Increases in baseline heart rate of at least 15 beats per minute, sustained for at least 15 seconds in term fetuses.
Decelerations:
- Reductions in FHR from baseline that may suggest various fetal conditions.

Fetal Monitoring: Decelerations

Types of Decelerations:
  - Late Decelerations:
    - Resulting from poor placental perfusion.
  - Variable Decelerations:
    - Due to cord compression.
  - Early Decelerations:
    - Considered benign, resulting from head compression during contractions.
  - Prolonged Decelerations:
    - A drop in FHR by at least 15 bpm persisting for 2 to 10 minutes.
Interventions for Decelerations:
  - Change maternal position.
  - Stop oxytocin infusion if in use.
  - Administer oxygen (8 to 10 L via nonrebreather mask).
  - Correct hypotension if a factor.
  - Notify the healthcare provider.

Labor Pain Characteristics

Personal Nature of Pain:
- Pain is subjective; affected by various factors including:
- Fear, previous labor experiences, support systems, and fatigue.
Manifestations of Labor Pain:
  - Pain in the abdomen, lower back, or thighs during contractions.
  - Persistent lower back pain may indicate fetal occiput-posterior positioning.
  - Continuous abdominal pain may signal placental abruption.

Labor Pain Management: Pharmacological

Medications:
  - Opioids:
    - Fentanyl: Short-acting (1–2 hours IM); risk of respiratory depression in patient/neonate.
  - Mixed Opioid Agonist/Antagonists:
    - Should not be administered to opioid-dependent patients due to the risk of withdrawal.
    - Have lower respiratory depression risks.
    - Examples:
      - Nalbuphine (Nubain): Lasts 3 to 6 hours.
      - Butorphanol (Stadol): Lasts 3 to 4 hours.
  - Nitrous Oxide:
    - Self-administered gas inhaled prior to contractions; side effects include nausea, vomiting, and lightheadedness.

Labor Pain Management: Nonpharmacological

Techniques include:
  - Focused breathing
  - Hypnotherapy
  - Position shifts
  - Cutaneous stimulation
  - Aromatherapy
  - Music therapy
  - Counter-pressures
  - Other diverse methods.

Assessment Questions

Question #1

Scenario:
  A midwife reports that the contractions are less frequent and intense than desired. What is the likely order from the provider?
  - A. Pain medications for relaxation.
  - B. Oxytocin to enhance labor.
  - C. Sterile vaginal exam for fetal evaluation.
  - D. Pelvimetry for maternal pelvis assessment.
Correct Answer: B. Oxytocin to augment labor, increasing contraction frequency and intensity.

Question #2

Scenario:
  A patient’s cervix was 6 cm dilated and 100% effaced 2 hours ago, now appearing agitated and with increased contraction intensity. Next step for the nurse?
  - A. Check cervix for transition phase confirmation.
  - B. Discuss pain management options.
  - C. Notify provider about status changes.
  - D. Prepare for the second stage of labor.
Correct Answer: A. Check cervix for potential transition phase.

Question #3

Scenario:
  A continuous strip shows a baseline of 130 bpm, moderate variability, no accelerations or decelerations, and contractions every 3 minutes, lasting 60 seconds. Interpretation?
  - A. Category I FHR tracing requiring no intervention.
  - B. Category II FHR tracing requiring no intervention.
  - C. Category III FHR tracing requiring no intervention.
  - D. Category III FHR tracing requiring intrauterine resuscitation.
Correct Answer: A. Category I tracing, indicating reassurance and no necessary interventions.

Question #4

True/False Question:
Nonpharmacological pain management should only be utilized in the latent labor phase.
Correct Answer: False. Nonpharmacological measures are effective throughout labor stages, with some patients choosing non-epidural methods.