Labor And Delivery 3

Front 1

Causes of Labor Pain: Primary

Back 1

Involuntary muscle contractions

•Uterine cxs cause temporary anoxia to uterine and cervical cells as the blood supply to the cells is impaired by the stricture of blood vessels -> anoxia causes pain.

•As labor progresses, the cxs become longer and harder. The period of relaxation between cx is too short to allow adequate oxygenation -> ischemia to cells increases and anoxia increases.

Front 2

PAIN OF LABOR:other causes

Back 2

Second source of pain is the stretching of the cervix and perineum.

Other sources of pain:
1. Pressure on surrounding organs.
2. Traction and stretching of the supporting ligaments.
3. Traction on the tubes, ovaries, and peritoneum.

When the fetus is in a occipitoposterior position -> back labor

The occiput presses on the mother's sacrum with each cx, ->extreme discomfort.

Pain of labor not just physiological, also has a psychosocial component.

Term "Labor"

Person's expectations of pain in labor + Their previous experience with pain +One's cultural concept of pain -> Affect the perception of pain and individual's response to pain.

Front 3

PAIN OF LABOR: Gate Control Theory

Back 3

Pain is transmitted by small diameter nerve fibers.

By stimulation of large diameter nerve fibers, these small nerve fibers can be blocked

The gate control theory proposes that there is a "gating mechanism" involved in the transmission of pain impulses.
oA closed gate = No pain
oAn open gate = Pain
oA partially open gate = Some pain

This gating mechanism is located in various places throughout the CNS.

When the gate is closed -> transmission of pain impulses is stopped -> Pain does not reach the level of awareness.

The gate is opened by excitation of small diameter fibers that carry pain impulses.

These pain signals can be blocked by stimulation of large diameter fibers.

Therefore, the gate can be closed to prevent or decrease their transmission to the cortex.

Many cutaneous fibers are large diameter fibers, so stimulation of the skin by rubbing can result in pain relief.

Front 4

PAIN OF LABOR:Gating theory can be used to control pain in labor.

Back 4

Distraction can also inhibit pain impulses.

A sufficient amount of sensory input may cause inhibitory signals to the gate -> causes the gate to be closed to the transmission of pain impulses -> so that pain signals do not reach the level of the cortex or fewer pain signals reach the brain.

Front 5

PAIN OF LABOR: Stages of Labor and Pain

Back 5

Pain in the first stage of labor is transmitted through the spinal nerve segment of T 10-12 and accessory lower thoracic and lumbar sympathetic nerves.

Second stage of labor, Pain impulses are carried through S 1-4 and the parasympathetic system from the perineal tissue.

Third stage, uterine cxs similar to the first stage of labor.

Front 6

Pharmacological treatment

Back 6

-Considerations-
-Maternal drug action important-as well being of the fetus depends on adequate functioning of the maternal cardio-pulmonary system.

-Any maternal alteration -> fetal environment affected.

Front 7

Pharmacological treatment:
Optimal time for administering

Back 7

General rule:
oNulliparas - when the cervix is 5 - 6 cms dilated.
oMultiparas - when the cervix is 3 – 4 cms dilated.
*Analgesics given too early may prolong labor and depress the fetus.
*Analgesics given too late is of no value to the women and may cause neonatal respiratory depression.
*Currently, a minimal amount of an analgesic is given during labor.
*IM and IV routes only.
*IV route preferred.

Front 8

Pharmacological treatment

Back 8

*Narcotic Analgesics can be used in labor: - Sublimaze

*Narcotic Antagonist - Narcan
*More commonly, mixed compounds provide analgesia without respiratory depression:
- Stadol
- Nubain
*Sedative/Hypnotics - also used for antiemetic actions:
- Phenergan
- Vistaril
- Sparine
*Barbiturates (Seconal or Nembutal) - useful in false labor to stop cx's or very early labor to promote relaxation and allow woman to sleep, and then enter active labor more relaxed and rested.

Front 9

Pharmacological treatment:
Regional Analgesia and Anesthesia

Back 9

*Injecting anesthetic agents into an area -> drug in contact with nerves -> blocks transmission of painful stimuli from uterus, cervix, vagina, and perineum to the brain.
*Types used in childbearing:
1. Peridural Block (Lumbar Epidural)
2. Pudendal Block
3. Local Infiltration
*Regional anesthesia may be a single injection or continuous via an indwelling plastic catheter.

Front 10

Spinal Nerves

Back 10

•Spinal nerves in the cord are protected by a number of different layers of tissue:

oPia Mater - membrane adhering to the nerve fibers.
Surrounding this is the cerebral spinal fluid.
oNext - the arachnoid membrane.
oNext - the dura matter.
oOutside the dura mater is the epidural space.
oBeyond the epidural space is the ligamentum flavum.

Front 11

Review of Spinal Nerves

Back 11

•Spinal nerves in the cord are protected by a number of different layers of tissue:
oPia Mater - membrane adhering to the nerve fibers.
Surrounding this is the cerebral spinal fluid.
oNext - the arachnoid membrane.
oNext - the dura matter.
oOutside the dura mater is the epidural space.
oBeyond the epidural space is the ligamentum flavum.

Front 12

Lumbar Epidural (Peridural Block)

Back 12

Anesthetic is placed in the epidural space in the lumbar region.

Blocks the spinal nerves in the epidural space and also sympathetic nerve fibers.

For vaginal delivery - block T 10 to S 5.
For C/S block T 8 - S 1.

The diffusion of epidural anesthesia depends on the:
1.Location of the catheter tip.
2.Dose and volume of the drug.
3.Woman's position

Most often a continuous infusion pump.

Can be administered anytime in active labor, but traditionally begun when the cervix is 5 - 6 cms in primigravidas, and 3 - 4 cms dilated in multigravidas.

Does not alter the labor pattern if client in good labor

Front 13

Lumbar Epidural: Contraindications

Back 13

Contraindications:
- Infection at the site of puncture.
- Maternal coagulation problems or anti-coagulation therapy.
- Disease of the spinal cord or nerves.
- Chronic placental insufficiency
- Rapid labor that needs immediate anesthesia.
Many agents have been used.
Frequently a combination of anesthetics and narcotics used.
ie: Fentanyl (Sublimaze) and Marcaine.
The major advantage of a combination is that there is less sympathetic blockage and that in turn results in less hypotension.

Front 14

Lumbar Epidural:Advantages

Back 14

Advantages of Epidurals:
1.Excellent pain relief.
2.May shorten the first stage of labor.
3.Partial motor paralysis.
4.Minimal blood loss.
5.Headaches are rare.
6.Prolonged anesthesia is feasible.
7.Alert, cooperative client.

Front 15

Lumbar Epidural:Disadvantages

Back 15

Disadvantages of Epidurals:

1.Clients can continue to feel some uterine pressure.
2.Onset may be delayed 10 - 20 minutes.
3.Considerable amount of the drug is necessary.
4.Bearing down effectiveness can be diminished.
5.Rapid absorption of the drug can lead to hypotension, paresthesia, and convulsions.
6.Variability of the fetus may be decreased

Front 16

Lumbar Epidural:Severe complication

Back 16

Severe complication: RESPIRATORY IMPAIRMENT:
-Diaphragmatic Paralysis.
-Breathing difficulty.
-Severe anxiety.
Cardiac impairment can also occur.

Front 17

Epidural:Nursing Care

Back 17

•Before initiating Epidural:
oHYDRATION is extremely important.
oHydrate with 500 – 1000mL of a NON-GLUCOSE balanced salt solution 15-30 minutes prior to procedure.
•Baseline vital signs and Fetal Heart Rate (FHR) and variability.
•Have client void prior to procedure.
•Provision for emergency Oxygen

Front 18

Epidural:Nursing Care
(Administration)

Back 18

Continuous monitoring of FHR and variability.

Vital signs are monitored.

Frequent bladder assessments.

Hourly assessments of lower limb movement.

-Monitor for progression of pronounced lower limb motor block.

-Monitor for a rise in sensory block.

If present: Anesthesiologist needs to DECREASE DOSAGE STAT!

Side Effects of Spinal Anesthesia can now be present: Headaches

May be postural and occur only with sitting up or standing.

Management:
- Analgesics.
- Bedrest flat for 8 hours.
- IV fluid @ 150/hr.
- Caffeine intake.

If Headache does not resolve: EPIDURAL BLOOD PATCH.

- A patch to repair the hole in the dura mater.

- A few mL's of the clients blood is injected epidurally at the puncture site-> forms a clot that covers the hole-> prevents further fluid loss.

Front 19

Pudendal Block

Back 19

Pudendal Block
-Provides perineal anesthesia for the second stage of labor.
-Relaxes the perineal muscles -> decrease in muscular resistance.
-Allows for use of low forceps for birth.
-Does not relieve the pain of uterine cxs.
-Injection of a local anesthetic bilaterally into the pudendal nerve after the client is 10cm dilated.
-Each side is blocked separately.
-The pudendal nerve is located at the level of the ischial spines, so the injection is made in the area just below and beyond the ischial spines.
-Using a transvaginal approach, the physician palpates the ischial spines with a finger and guides the needle.
-Onset is 2 - 10 minutes.
Effects last for one hour.
-Has no effect on mother's vital signs or FHR.

Disadvantage: Bearing down effort is lessened.

Front 20

Epidural

Back 20

Locals
•Used for episiotomy incisions and repair.
•Injection of an anesthetic into the superficial nerves of the perineum.
•Especially useful for natural childbirth clients.

General Anesthesia
•Used for severe fetal distress or when unable to do epidural for C/S.
•Disadvantage: Neonatal Respiratory Depression.

Front 21

HIGH RISK LABOR:Dystocia

Back 21

Types of dystocia (r/t to the 5 P's).

1.Dysfunctional Labor (Uterine Dystocia).
2.Pelvic Dystocia (Pelvic structure).
3.Fetal Dystocia.
4.Maternal position during labor and birth.
5.Psychologic response of the mother.r/t
- past experiences.
- preparation.
- culture and heritage.
- support system.

Front 22

HIGH RISK LABOR:Uterine Dystocia

Back 22

Normal labor pattern (effective uterine cxs).

Cx initiated in the fundus -> spreads toward the center and downward to the cervix.

Cx increase in intensity with maximum intensity first in the fundus, next in the midsection, then in the lower uterine segment.

Front 23

HIGH RISK LABOR:Ineffective uterine cxs (hypertonic)

Back 23

•Hypertonic cxs
oIncrease in the resting tone of the myometrium.
oFrequency of cxs is increased and intensity is decreased.
oCx are ineffective in dilating and effacing the cervix.
oLeads to a prolonged latent phase of the first stage of labor.
oVery Painful.
oBecause hypertonic cxs occur in the latent phase of the first stage of labor (when 2-3 cms dilated) -> client often accused of overreacting to labor.
oFetal distress can occur early.
Management Goal: Arrest uterine activity and establish a more effective labor pattern.

Front 24

uterine cxs (hypertonic):
Management
Nursing Care

Back 24

•Management
Therapeutic rest with the administration of analgesics to reduce the pain.
Women often awaken with normal labor patterns.
•Nursing Care
Promote an environment that is conducive to relaxation.
Interventions to decrease client's anxiety level.
Safety precautions.
Comfort measures.

Front 25

HIGH RISK LABOR:Ineffective uterine cxs (Hypotonic)

Back 25

Hypotonic cxs

Initially the client has normal labor progress.
In active phase of the first stage of labor: cxs become weak, infrequent, and ineffective.

Front 26

uterine cxs (Hypotonic):
Causes

Back 26

Causes of hypotonic cxs:

1.Uterine muscle fibers are overstretched.
2. Sedation.
3. Cephalopelvic Disproportion (CPD) or malpositions.

Risk: Infection may result with prolonged labor.

Front 27

uterine cxs (hypertonic):
Management

Back 27

•r/o CPD.
•Augmentation of labor.
•Oxytocin (Pitocin) - a synthetic endogenous hormone.
oStimulates rhythmic cxs of the uterine muscle.
oOnset: Immediate.

Front 28

uterine cxs (hypertonic):
Nursing Care of client receiving Pitocin

Back 28

•Baselines:Maternal vital signs.
•External Fetal Monitoring (EFM) for 30 minutes.
•At 30 - 60 minute intervals, the dose is gradually increased in increments of 1 -2 milli units, until desired cx pattern is established.
•Need to meet all of the following criteria to increase the dose:
1.FHR is reassuring.
2.Labor progress is <0.5 to 1cm/hr.
3.Cx are no closer that q 2 min.
oAssess contraction pattern.
oAssess FHR.
•Administered IV with infusion pump.
•Run Piggyback to a physiologic electrolyte solution (primary line).
•Low initial dose: 0.5 - 1 m U/min.

Front 29

uterine cxs (hypertonic):
Nursing Care of client receiving Pitocin part II

Back 29

•Assess uterine response.
Desired pattern:
- Moderate-strong cxs.
- Duration 40 - 60 seconds.
- Frequency 2 1/2 - 4 minutes.
- Intensity 50 - 75 mm Hg if Intrauterine pressure monitor used.
•Once dilated to 5 - 6 cms and labor is established, oxytocin can be decreased by similar decrements.
•Continuous monitoring q 30 - 60 minutes:
- FHR.
- Uterine resting tone.
- Frequency, duration, and intensity of cxs.
-Maternal B/P and pulse.
•Monitor I & O carefully to prevent water intoxication.
•Assess for other side effects:
- Nausea/vomiting.
- Headaches.
•D/C Oxytocin immediately if:
- Fetal Distress.
- Uterine hyperstimulation
--> More than 5 cxs in ten minutes.
--> Cx < 2 minutes in frequency or > 90 seconds in duration.
--> Elevated uterine resting tone.
Other potential dangers:
- Uterine rupture.
- Abruptio Placenta.

Front 30

HIGH RISK LABOR:Pelvic Dystocia

Back 30

Pelvic Dystocia:
A contracture of one or more of the pelvic diameters -> reduce capacity of the pelvis.
•Involves the Inlet,the Midpelvis, and the Outlet.
•Causes:
- Congenital abnormalities.
- Maternal Malnutrition.
- Neoplasms.
- Spinal disorders.
- Immature Pelvis: Teenagers
(Mature pelvis = age 20).
•Inlet contractures
oEngagement and fetal descent prevented.
oResults in malpresentations and positions -> higher incidence of prolapsed cord.
oManagement: C/Section.
•Midpelvis contracture - Most common.
oFetal descent arrested r/t fetal head can not internally rotate.
oManagement: C/Section.
•Outlet contracture
oAssociated with long narrow pubic arch and android pelvis.
oRarely occurs without midpelvis contracture.
oComplication: Perineal lacerations r/t fetal head pushed posteriorly.

Front 31

HIGH RISK LABOR:Fetal Dystocia

Back 31

•Causes:
- Congenital Anomalies.
- Excessive size (Macrosomia).
- Malpresentation.
- Malposition.
- Multiple gestation.
•Congenital Anomalies
- Gross ascites, tumors
- Conjoined twins
- Myelomeningocele
- Hydrocephalus
•Interferes with the relationship of fetal anatomy to the maternal pelvis.
•Management: C/Section.

Front 32

HIGH RISK LABOR:Macrosomia

Back 32

Macrosomia: 8 pounds 13 1/2 ounces or larger. r/t
*BOOK* infants that weight 4000g or more- at risk for dystocia, traumatic injury, and asphyxia during birth

- Maternal Diabetes.
- Maternal Obesity.
- Large size of one or both parents.

Front 33

Shoulder dystocia

Back 33

Shoulder dystocia: When the head is born, but the anterior shoulder can not pass under the pubic arch.

Mother needs to change position to free the shoulders.

Front 34

McRoberts Maneuver

Back 34

McRoberts Maneuver: Mother's legs flexed with knees on her abdomen -> causes sacrum to straighten and symphysis pubis rotates toward the mother's head -> the angle of pelvic inclination is decreased -> shoulder can be delivered.

Front 35

Suprapubic pressure

Back 35

Suprapubic pressure: Nurse uses the palm of the hand to apply pressure directed away from the pubic bone, while the MD applies gentile traction downward.

Front 36

Breech presentation

Back 36

•Causes:
- Multiple gestation.
- Preterm birth.
- Maternal anomalies.
- Hydromnios.
•Associate with birth trauma and asphyxiation.
Management
•External Cephalic Version: Turning the fetus to a vertex presentation by exerting pressure on the fetus externally through the maternal abdomen.
•C/Section

Front 37

Face and Brow Presentations

Back 37

•Associated with fetal anomalies, pelvic contractures and CPD.
•Management
Vaginal birth is possible is fetus flexes to a vertex position.(Forceps may be used).
•C/Section.

Front 38

Shoulder Presentations

Back 38

Management: C/Section.

Front 39

Malpositon

Back 39

•Most common: Occiptoposterior (right or left).
•Prolonged second stage.
•c/o severe back pain.
•Positioning used to facilitate rotation of the fetus from posterior to anterior position.
•Alternate q 15 minutes: Sims and Prone Knee Chest ( all 4’s)

Front 40

Malpositon: Theory of Knee Chest

Back 40

•Back is the heaviest densest part of the fetus.
•Two forces act on rotation: gravity and buoyancy.
•If forces are sufficient, fetal body will rotate.
oFetal back -> lower side
oSmall parts -> upper side
•The head will then rotate.

Front 41

Malpositon:Multiple gestation

Back 41

•Multiple gestation: More than one fetus (twins, triplets, quadruplets or more).
•High perinatal mortality r/t
- low birth weight
- Preterm birth
- IUGR
•Abnormal presentations -> Higher incidence of C/S.

Front 42

Malpositon:
Position of the mother
Psychologic Response

Back 42

•Position of the mother
oDiscouraging maternal movement or restricting labor to the recumbent or lithotomy position may compromise labor -> need for augmentation of labor, use of forceps, vacuum extraction, and C/Section.
•Psychologic Response
oHormones released in response to stress can cause dystocia(prolonged labor).
oStress -> increase pain perception.

Front 43

Methods of management for dystocia:
Trial of labor
Induction of labor

Back 43

•Trial of labor
oFour - six hours of active labor.
oUsed to assess the safety of vaginal birth for the mother and fetus
oR/O CPD.
•Induction of labor
oInitiation of uterine cxs before spontaneous onset.
oReasons:
- Pregnancy Induced Hypertension (PIH)
- Maternal Diabetes
- Post-term gestation
- Suspected fetal problem