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53 Cards in this Set
- Front
- Back
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Birth Process
What starts labor? |
Hormones contribute, progesterone from the placenta goes away, prostaglandins help induce labor, uterus becomes more sensitive to oxytocin levels causing uterine contractions, uterine distention
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Birth Process
What are the signs of impending labor? |
Lightening, easier breathing, more frequent urination, lower back pain, increased Braxton Hicks contractions, increased vaginal mucus, bloody show, weight loss right before delivery due to water loss from electrolyte shift, increased energy level (nesting)
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True labor
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regular
strength, frequency duration felt in lower back and radiate to abdomen Cervix changes and defines true labor moves anterior shows progressive change |
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False labor
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irregular
may even stop with walking felt in low abdomen, groin |
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ruptured membranes
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Not everyone has ruptured membranes before labor, if membranes rupture you want mother to delivery within 24 hrs, may have to induce, ruptured membranes increase risk of infection
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Critical Factors in the Process of Labor
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all 5 must be in synch for functional labor
Passenger Passageway Powers Maternal Position Psychological |
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Passenger - Baby and Placenta
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Size of fetal head and shoulders
Presentation – part of the baby that visits pelvic region first (cephalic – can be occipital , brow or face first, breach, or shoulders) Lie – relationship of long access of the mother (spine) and that of the fetus, can be longitudinal (can usually be delivered vaginally )where they are aligned or transverse where they are perpendicular Attitude – baby’s posture, want chin on chest, nice and rounded, presents smallest diameter of head in the pelvis with an average of 9.5cm (up to 13.5 if face first) Position 3 letter abbreviation, relationship of presenting part to the four quadrants of the mother’s pelvis LOP, ROA, LOT Station centimeters above or below ischial spines At ischial spines = 0 station, below is positive, above is negative 2 nursing concerns pre-engagement of the fetal head are the size (CPD – cephalo-pelvic disproportion) in proportion to the passage way and the umbilical cord |
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Passageway
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rigid bony pelvis
soft tissues cervix thins or effaces opens or dilates – 10 cm is the end of the first stage of labor, if mother pushes before the cervix will develop edema and you have to wait for it to go away |
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Powers
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Primary - contractions
involuntary frequency (measured in minutes, usually a range), duration (always measured in seconds), intensity effacement and dilatation secondary pushing |
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Maternal Position
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relieves fatigue
promotes comfort improves circulation – lying supine decreases circulation by 25%, keep her off her back, signs will be decrease in mother’s blood pressure, decrease in baby’s heart rate shorten course of labor – different positions can help the baby move, can make her a more effective pusher, can stretch out tissues |
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Psychological
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Emotions can influence length of labor
Anxiety Support Education – clear information on procedures, knowing the process and what to expect |
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Mechanism of Labor - Seven Cardinal Movements
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Engagement
Descent Flexion Internal Rotation Extension Restitution and Ext Rotation Expulsion |
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Physiologic Adaptation to Labor
Maternal |
Cardiovascular – increase HR, BP and CO, always take BP in between contractions
Respiratory – increase RR and oxygen consumption, watch for hyperventilation GI – decreased gastric motility and emptying, n/v Musculoskeletal – aches and cramps Renal – difficulty in urination, remind her to urinate at least every 2 hrs Increased WBC, increased metabolic rate, diabetics may need shift in insulin requirements |
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Physiologic Adaptation to Labor
Fetal |
heart rate – periodic accelerations and decelerations, average is 140
circulation – decrease and also decrease in perfusion respiration - |
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Stages of Labor
1st Stage |
begins with the onset of regular uterine contractions and ends with full cervical dilatation, longest stage of labor
3 phases: Latent – early, up to 3cms, contractions average at 30 seconds, 5 to 30 minutes apart, more effacement but very little descent, want the mother at home Active – 4-7 cms, contractions average 45-60 seconds, 3-5 minutes apart Transition – shortest phase, 8-10 cms, 60-90 seconds, every 1-2 mins |
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Stages of Labor
2nd Stage |
begins at full dilatation (10 cm) of the cervix and ends with delivery of the baby, pushing, needs lots of coaching, most stressful time on the mother and the fetus, will likely have oxygen at 10 liters on
primipara average: 1- 2.5 hours multipara average: 1 hour |
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Stages of Labor
3rd Stage |
begins with birth of baby and ends with delivery of the placenta
normal within 3-5 minutes but can last up to one hour risk of hemorrhage increases as length of 3rd stage increases |
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Stages of Labor
4th Stage |
first two hours after delivery
homeostasis is re-established in recovery room, after that she is transported back to her room |
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Nursing Care Through the 1st Stage of Labor
Admission Assessment |
initial contact – first question is about when her due date is, if she’s at term we look at symptoms differently, preterm labor is handled much differently, if on the phone we ask about fetal movement in the past few days, any signs of labor, if she’s had a baby and previous experiences if she did, time frame for previous labors, frequency, intensity and duration of contractions, bloody show, membranes intact? Supportive adult with her? Let her know when to come in, if membranes are suspected to have ruptured she needs to come in
prenatal record – weight gain, medical surgical history, OB history, allergies, history of this particular pregnancy, lab values, if unavailable we need to ask her all the questions and draw pertinent labs interview physical exam – amniotic fluid is alkaline and will turn blue, check to see if it’s actually urine bowel movement in utero can indicate that baby is in distress, fluid would be greenish, the amount could indicate how long the baby has been in distress and if it could tolerate labor limited vaginal exams if premature rupture of membranes occurs to avoid infection before labor begins |
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Nursing Care Through the 1st Stage of Labor
Ongoing Assessment |
table 14-3
Vital signs – temp more frequently after membranes rupture Cervical exam Contraction patterns – don’t want contractions to last more than 90 seconds, too much stress on mother and baby, should be at least 60 seconds Fetal heart rate (FHR) – worried about prolapsed cord stopping profusion, bradycardia Rupture of membranes – bloody could indicate placenta is breaking away, watch for fetal tachycardia above 160 for at least 10 mins to indicate baby is getting an infection Intake and output – could look for protein or ketones, empty bladder at least every 2 hours, full bladder can prolong labor Positioning Emotional changes and coping ability Pain Tachysystole – too many contractions (2 mins apart) |
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Nursing Care Through the 2nd Stage of Labor –
Assessment |
cervical dilation of 10cm
Signs and symptoms Cervical exam Increased stress to fetus |
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Nursing Care Through the 2nd Stage of Labor –
Nursing interventions |
positioning and pushing – if the mother is dilated 10cm but doesn’t feel the urge to push she may wait for the urge and rest (called laboring down), will allow her to push more effectively when she is ready, want her sitting up with her legs held up, chin on chest when pushing, hips down and not lifted, back is rounded
voiding pain management Preparation for Birth warmer equipment staff Episiotomy Immediate Care of Newborn Airway / oxygen Warmth - dry Assess for obvious abnormalities check cord - 2 arteries, 1 vein / clamp Apgar score at 1 and 5 minutes Bonding Meds - within 1 hour: eye (to prevent Chlamydia or Gonorrhea of the eyes, state law) / Vit K 1mg to prevent hemorrhagic complications |
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Nursing Care through Third Stage
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Assessment
Placental separation , give pitocin afterward to prevent more bleeding, do not pull on the cord, cord will start to lengthen, increase in bleeding, will feel more like and orange (3 signs the uterus is ready to come out) Placenta and fetal membranes examination Perineal trauma Episiotomy and/or lacerations – first degree just the vaginal mucosa, second degree, 3rd anal sphincter, 4th degree is through the rectal wall (can cause a fistula) Interventions giving oxytocin if ordered |
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Nursing Care through Fourth Stage
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Assessment
VS q 15 mins for first hr and q 30 mins for 2nd hr except for temp which is right away and right before she is moved, fundal check, perineum, and lochia (bleeding from placental site) Check for bladder distention Comfort level Interventions Support and information Fundal checks (if boggy, may have to massage); perineal care and hygiene (ice to decrease edema, swelling could prevent urination or cause a hematoma to form) Bladder status and voiding Comfort measures Parent-newborn attachment Teaching Fundal Massage Bonding |
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Fetal Monitoring
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Baseline Fetal Heart Rate
Average FHR during a 10 minute period Normal 110-160 Concepts related to the baseline Bradycardia tachycardia variability |
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Fetal Monitoring
Bradycardia |
Bradycardia
<110BPM sustained for 10 minutes etiology hypoxia, late sign drugs heart block treatment variability adequate-watch ominous sign with decreased variability oxygen, lateral position prepare for operative delivery (could be anything to facilitate delivery, not just surgery) |
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Fetal Monitoring
Tachycardia |
>160 for 10 min.
etiology maternal fever early hypoxia drugs arrhythmias treatment variability adequate-watch lower maternal temperature oxygen ominous sign with decreased variability, prepare for delivery |
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Fetal Monitoring
Variability |
the change in the FHR due to the interplay of the PNS and the SNS (imp indicator)
normal variability indicates an intact medulla, mature CNS, and a perfused, oxygenated CNS Classification (external monitor) Present, decreased, or absent Classification (internal monitor) Absent: amplitude range undetectable Minimal: amplitude range detectable but 5 beats per min or fewer Moderate (normal): amplitude range 6-25 beats per min Marked: amplitude range greater than 25 beats per min Variability most accurate with internal monitor etiology of decreased variability hypoxia/acidosis drugs sleep anomalies tachycardia treatment drugs- none if on external monitor place internal lateral position increase IV fluids stop pitocin if in use scalp stimulation/sampling |
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Fetal Monitoring
Periodic Changes |
Increase or decrease in baseline in response to contractions or fetal movement
Types early deceleration late deceleration variable deceleration accelerations |
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Fetal Monitoring
Periodic Changes |
Increase or decrease in baseline in response to contractions or fetal movement
Types early deceleration late deceleration variable deceleration accelerations |
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Periodic Changes
Early decelerations |
mirror image of the contraction
shallow, rarely below 110 caused by head compression vagal stimulation no treatment required |
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Periodic Changes
Variable decelerations |
abrupt deceleration that varies from one contraction to another
most common type caused by cord compression (pressure on the cord) treatment change position VE to R/O cord prolapse D/C pitocin, increase IV fluids oxygen amnioinfusion tocolytics (medications to stop contractions) |
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Periodic Changes
Late decelerations |
decrease in the FHR which starts late in the contraction and recovers well after the end of the contraction
caused by uteroplacental insufficiency most serious type of deceleration, even when very subtle, at least 50% contractions have lates in 10 minutes treatment D/C pitocin if infusing, too much is usually the cause and she is hyperstimulated increase IV rate lateral position oxygen correct hypotension scalp stim/sampling prepare for operative delivery treatment will always be more aggressive if variability is decreased |
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Periodic Changes
Accelerations |
positive sign on fetal wellbeing
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Causes of Periodic Changes
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Variable
Cord compression Turn Early Head compression Okay Nothing Accerlation Okay Acceptable Late Placental insufficiency STOP stop pitocin, turn, 02, plain IV increase) |
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Types of Monitoring
External |
indication-routine, non-invasive
contraindications- none, does decrease the patient’s mobility method FHR - ultrasound transducer variability not as accurate present, absent, or decreased active fetus hard to trace dead fetus may pick up mom’s pulse uterine contractions- tocotransducer used which has a pressure sensitive button to be placed on the fundus measures freq and duration only freq-beginning of one to beginning of the next, adequate q 2-3 min duration-beginning to the end of the same contraction, max 80-90 seconds strength only relative |
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Types of Monitoring
Internal |
Indications
non-reassuring pattern on external monitor meconium stained fluid any high risk pregnancy dysfunctional labor Contraindications active herpes, HIV, Hep B high presenting part, ROM necessary method- FHR fetal scalp electrode applied to the presenting part which picks up an electrical impulse much like and ECG accurate assessment of variability remote but possible risk of infection/ injury to the fetus increased risk of maternal infection probably related to length of ROM and freq exams associated with the labor method- uterine contractions catheter filled with fluid inserted into the uterine cavity and measure the pressure within the uterus during and between contractions accurately measures freq, duration and strength strength in mm of Hg intensity up to 75mm is normal, resting tone 5-15mm, subtract resting tone from the height of the contraction then add them up (want between 180 and 220 to show that it’s a productive labor) Montevideo units sometimes used increased PP endometritis |
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Fetal Monitoring
Interpretation of External |
External
What is the baseline? Is there variability? pres/decr/absent Are there any periodic changes? Reassuring/nonreassuring? How frequent are the contractions? How long do they last? What is the intensity? Is there adequate rest in between? |
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Fetal Monitoring
Interpretation of Internal |
Internal
What is the baseline? Is there variability? Absent/min/mod/marked Are there any periodic changes? Reassuring/nonreassuring? How frequent are the contractions? How long do they last? What is the strength and resting tone? Is there adequate rest in between? |
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Pain Relief through the stages
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1st Stage - cervical change and uterine ischemia
visceral pain - during contractions 2nd Stage - stretching of perineal tissue and traction on peritoneum and uterocervical supports perineal or somatic pain |
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Goals of Pain Relief
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adequate pain relief
does not affect progress of labor does not increase maternal or fetal risk |
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Pain Relief
Non-pharmacological |
Education – fear of the unknown intensifies pain, biggest factor
relaxation visualization breathing effleurage and sacral pressure |
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Sedatives
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biggest concern is central nervous system depression (hypotonia, respiratory depression, decreased variability)
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Systemic analgesics
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always check cervix first, don’t want to give it if the baby will be born within the next hour, want it metabolized by mother first
narcotics mixed narcotic agonist/antagonist – most common, don’t give to someone with narcotic addiction because can cause immediate withdrawal potentiators – to decrease anxiety and help with side effects of narcotics narcotic antagonists – must always have on hand for both adults and newborns, narcan has a shorter half life than narcotics and wears off faster |
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Regional anesthesia
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Local – only for tearing and episiotomy
Pudendal – (for delivery) given as a shot vaginally Spinal (active labor 4cm) Epidural – local and some systemic put in epidural space |
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Epidural
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Contraindications – those with severe hypotension, allergy, infection near site
Preprocedure – education and consent signed, preload mother with 500-1000cc’s of IV fluid because of maternal hypotension that it can aggravate, everyone gets preloaded, after it’s given take bp every five minutes Postprocedure - monitor patient response and level of medication, might turn patient to distribute medication, check bladder for distention, monitor blood pressure, put a foley in, take foley out when she’s ready to push, have ephedrine available incase bp drops |
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General Anesthesia
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for emergency cesareans
Complications – fetal depression, uterine relaxation could increase bleeding, vomiting, aspiration, neuro behavior depression in the infant for up to 8 hours, transient tachypnea for the baby because born with more fluid in the lungs (over 60) and can’t feed the baby orally care during/ after general anesthesia |
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Operative deliveries: Vacuum, Forceps, Cesarean
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Vacuum Extraction
facilitate delivery mother cannot or should not push fetal distress maternal risks – trauma, lacerations, hematoma fetal risks – cephalohematoma (does not cross suture lines) Forceps Two blades lock to prevent compression of fetal skull maternal risks – have mother empty bladder before use to prevent trauma fetal risks – must get fetal heart tones before and after application and note them, bruising facial injury or neuro brain damage |
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Cesarean Section
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Terminology
Primary – first time having one Repeat – most common Elective – planned and scheduled prior to labor starting VBAC – vaginal birth after cesarean Indications – fetal distress, failure to progress, active maternal herpes infection Nursing Concerns – mortality is 4 x’s higher than that of a vaginal delivery, more uti’s, pneumonia, illius, trouble holding the baby in a breastfeeding position, blood clots |
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Induction of Labor
(Augmentation means mother is in labor but it’s not progressing) Cervical Ripening |
used for induction, first time mothers need a score of 9 to be considered for induction, after that only a 5 is needed (Bishop’s score)
Prostaglandin gels – need to stay flat for 15-30 minutes after insertion, needs to be a 4 hour window between using the gel and starting Pitocin to avoid hyperstimulation Mechanical – dried seaweed in cervix, foley cath in cervix |
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Induction of Labor
(Augmentation means mother is in labor but it’s not progressing) Amniotomy (AROM) |
so that baby’s head and press directly on the cervix (considered an augmentation), can’t use for induction because it starts the 24 hour time clock and after that chance for infection increases significantly, make sure to check fetal heart tones for one minute to make sure there’s not a prolapsed cord, want to decrease cervical exams if possible after the amniotomy because it could cause an infection
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Induction of Labor
(Augmentation means mother is in labor but it’s not progressing) |
Oxytocin induction or augmentation
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Nursing Care during Induction of Labor
Pitocin |
goal: contractions q 2-3 min lasting no longer than 80-90 sec, if lasts longer it’s a kitanic contraction, if either is the case (too often or too strong) Pitocin will be discontinued or if more than 50% have a late fetal increase in heart rate
watch for tachysystole (contractions too often) / hyperstimulation ideal to have IUPC (internal uterine pressure catheter) /Montevideo units (have to subtract the resting tone, measure for 10 minutes on monitor strip, 180-220 is considered good, if under they are a good candidate for augmentation) Concerns tissue perfusion high risk for maternal injury excess fluid – water intoxication (Pitocin is an anti-diuretic) maternal fatigue Increased chance of post-birth hemorrhage because uterus may not clamp after birth if too much Pitocin has been given Interventions always on a pump, increased at specific amounts at specific intervals, nurse decides if it’s increased or shut off piggybacked into main line at port closest to patient orders for starting dose / interval increase / max dose nurse decides if pitocin increased or shut off |
