Labor and Delivery-Intrapartal

8/3/2019 Labor and Delivery-Intrapartal

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Michelle L. Murray, PhD, RNC-OB

Family Nursing 2580

Spring, 2012

Identify the 2 phases and 4 stages of labor.

Create a plan of care for an uncomplicated labor.

Discuss the collaborative role of the nurse when there is acomplicated labor.

Identify FHR patterns that are ´reassuringµ or Category 1or ´nonreassuringµ or Category 2 or 3.

List 5 things the nurse can do when there is a Category 2 or3 FHR pattern.

Refer to the syllabus for learning content.

Keryotype-chromosome found with amniosythesis

By the end of this semester you should be able to:

After reading the chapter and by the end

of this seminar you should be able to:

1. List 2 signs of impending labor.

2. Differentiate 3 signs of true vs. false labor.

3. Understand the role of prostaglandins andoxytocin.

4. List 3 signs of preterm labor (PTL).

5. Discuss problems of the 3 Ps: Psyche, Passenger,and Powers.

6. Describe the nurse·s role when a patient has PTLor there are decelerations in the FHR.

Signs of Impending Labor

False Labor and True Labor

Physiology of Labor

Preterm Labor The 4 Ps of Labor: Psyche, Passenger,

Passageway and Powers

Dystocia

Fetal Heart Rate Monitoring: Overview

May experience 1 or more: Braxton-Hicks contractions (increase) Backache (Relaxin: peptide hormone breaks

down collagen-widens pubic bone) Lightening: fetus descends (pelvic inlet) Cervical ripening (softening; Relaxin) Bloody Show: mucus plug plus streaks of

blood GI symptoms (possible): D/N/V/indigestion Energy spurt (possible): 24-48 hours prior to

birth ROM: 12% rupture before labor, 80% will go into

spontaneous labor after, if not, expect labor within 12-24hours and induction

False labor Contractions irregular Walking MAY relieve

contractions

Bloody show usually

not present

No change in dilatationor effacement of cervix

True labor UCs gradually develop a pattern

and intensify over time Myth: UCs are more effective

with walking

Discomfort in lowerback/abdomen

Bloody show often present

Progressive dilation andeffacement of the cervix

Hormonal changes:

Progesterone decreases

Prostaglandins are

produced

Oxytocin receptors

increase

Oxytocin is released Fetal hormone (oxytocin)

production

Uterine distention (myth)

4 Stages

2 or 3 Phases

1st Stage

2nd Stage

3rd Stage

4th Stage

Stage: Latent Phase, Active Phase or Latent Phase, Active Phase, Deceleration

Not hormones but mediators

Derived from fatty acid (arachidonic acid)that has been acted on by cyclooxygenase

(COX-2) AA + COX-2 PGF2 or PGE2

Cytokines can trigger production of PGs

Increase calcium in the uterine cells

Calcium is a messenger of force

Oxytocin bound to Oxytocin Receptors

Triggers the production of prostaglandins

Increases the amount of calcium in the uterine muscle cells.

Labor that starts after the 20th week butbefore the end of the 37th week

Etiology not always fully understood

1/3-placental factors, 1/3-infection, 1/3-other Other:

Maternal medical conditions (such as appendicitis)

Use of reproductive technologies/Preeclampsia

Genetics

Social (stress, trauma)

Environmental factors (like what?)

Drugs (especially cocaine)

Demographics (such as?)

Signs and Symptoms

Often subtle

Intermittent cramps, may or may not be aware or

interpret as painful Low backache; constant, or intermittent, irregular

Pelvic pressure; pressure in vulva or thighs

Abdominal cramps; may have diarrhea

Change or

in vaginal discharge Cervical changes

Cervical effacement of 80% or > or dilatation of > 1 cm

Just not feeling good

Issues:

Physical

Emotional

Financial

Ethical

In-hospital care

Viability/Gestational Age

Duration of Care

Community education Factors that risk Consequences of preterm birth

Prenatal care Importance and access

ID at risk population

Nutrition

Educate: signs and symptoms

Women and significant other:

role in seeking care

Diagnosis of Preterm Labor

Physician diagnosis (not RN diagnosis)

Call the physician and ask them to come to the bedside

Nurse·s role: physical assessment, may draw blood

and/or submit order for lab studies Set up for SSE (sterile speculum exam)

Bring portable Ultrasound to bedside

Provide Fetal fibronectin (fFN) swab

´The glue that holds the placenta down.µ

A sticky glycoprotein present on the back of theplacenta

Fibronectin receptors in the decidua

Results: Negative ~ 22-37 wks; if positive, risk pretermbirth within 2 weeks

Physician may assess length of cervix (if vaginalultrasound should be 3 cm +/-)

If less than 25 mm 2.5 cm): vaginal microorganismshave a shorter distance to access the uterus

Infection/endotoxins may weaken membranes,resulting in PPROM (ppreterm ppremature rrupture oof the mmembranes)

RN Role: Assess for signs and symptoms of infectionand rupture

Nitrazine

Fern test: A positive test shows thepresence of fern-like patterns characteristicof amniotic fluid crystals.

Supplies:

Sterile speculum exam (SSE)and sterile swab Access fluid in posterior fornix (if any)

Avoid collecting mucus (mucus plug)

Clean glass slide

Microscope

Can Preterm Labor Be Stopped?

Terbutaline (Brethine): Now FDA warning

Antibiotics (of no use once cytokines are

released)

Restrict activity if PPROM

Hydration: if dehydrated to release of AVP(arginine vasopressin/antidiuretic hormone)

Tocolytics (Beta sympathomimetics/adrenergics)(Ritodrine NOT AVAILABLE & Terbutaline FDA WARNING)

Side effects

HR (often hold if pulse > 120, or per protocol)

Hold and discuss with MD/DO if HTN or hyperthyroidism

or Diabetic Assess V/S, FHR and UA before and after

Breath sounds: shortness of breath, c/o palpitations(most common)

Metabolic changes: check blood glucose levels

Restlessness, tremors, nervousness Usual dose: 0.25 mg SQ (or IVP-dilute first)

Magnesium Sulfate (IVPB on a pump/buretrol

or volutrol: High-alert medication)

Calcium channel blocker

Decrease calcium - uterine contractions

Off-label use

Excreted in urine (strict I and O)

Assess deep tendon reflexes (DTRs), respiratorystatus, usually OK urinary output (notpreeclamptic)

Criteria to continue: UO 30 mL/hr, presence of

DTRs, min 12 resp/min Mg levels?

Reflexes, respirations, urine output q 1 hour

Tocolytics Calcium channel blockers ²

Nifedipine (Procardia)

Assess BP closely

Do NOT give close to MgSO4 discontinuation

Prostaglandin Synthesis Inhibitors (COX-2inhibitors) Indomethacin

Toradol (NSAID) Do NOT give after 32 weeks of gestation

Betamethasone (Celestone)

Corticosteroid

12 mg IM 24 hours apart

23-34 weeks of gestation

To stimulate surfactant development

´For lung maturityµ

45-50% decrease in respiratory distress

Photo from Wikipedia: en.Wikipedia.org/

Wiki/Preterm_birth

Psyche

Passageway

Passenger

Powers

From:www.vision.ee.ethz.ch

Factors influencing response

Labor experience: sense of control?

Childbirth preparation Expectations (Birth Plan?)

Identify stressors

Assess coping & support

Be nonjudgmental Support & show respect

Express confidence

Praise efforts

ANXIETY

Increased Pain

analgesia/anesthesia

Serum epinephrine

Uterine contractility

Length of labor

Norepinephrine increases number of contractions

Signal

Contraction

Unprepared Response Prepared Response

Anxiety, tension

muscular,

visceral

response

Self-image of

being unable to

Inability to

fragmented,

disorganized

responses

Concentration,

directed motor

activity

Cognitive

responses

Self-image being

able to cope

Continued coping

behavior

Nursing to anxiety Explore past experiences or family member

experiences

Identify cultural needs

Educate about the process and plan of care Provide supportive care«is there a doula?

Provide personal space

Consider alteration in body image (privacy)

Help maintain control Assess focus of attention, keep informed, allow choices,

Support childbirth prep techniques, reassure

Be a patient advocate

Orthodox Jewish patients prefer to bring their own food.Nurses can assist by facilitating refrigerator space in thepatient·s room, or on the unit.

One additional issue nurses may encounter is the

completion of birth certificates. Parents will not nametheir son until the baby·s eighth day of life when he isritually circumcised (brit milah or bris).

Girls are usually named in the synagogue by their fatheron the first Sabbath, or on a day during the week whenthe Torah is read.

It may require some flexibility and understanding of thistradition and holding paperwork for parents to returnafter these ceremonies have been completed.

Establish rapport:

Welcome family, determine family expectations,convey confidence, respect culture

Provide timely interventions

Keep them informed of when you will be in theroom

Descent through the pelvis

Engagement (tip of skull at level of ischial spines)

Flexion

Internal rotation

Extension

External rotation

Expulsion

An unengaged fetus at the onset of active

or (nulliparous women) is a risk factor for dystocia.

14% will be delivered by C-section.

Williams Obstetrics, 2005

THE PELVIS

4 types pelvis shapes

Gynecoid is ideal ~ 50% have

Engaged is when the TIP of

the skull is at the level of the

ischial spines

Posterior

abnormal labor

Mechanical Dystocia: due to passenger-passageway FIT problem

Includes Pelvic Dystocia: pelvis too small or

abnl shape Related to a malpresentation (e.g., face or brow) or

malposition (e.g., OT or OP)

Cord prolapse risk

Suspected protraction or arrest of dilatation and/or

descent

To Mom

To Baby

Placenta

Umbilical cord

Chorion/Amnion (membranes)

and amniotic fluid (500-1500 mL)

1. Fetal lie: relationship of long axis of fetus to long

axis of mother

± Longitudinal most common

2. Fetal attitude: pose assumed within the uterus

± Flexion most common ± Relationship of fetal body parts to each other

3. Presentation: portion of the fetus coming first

± Cephalic

± Breech

± Shoulder

Problems with passenger can be R/T:

Fetal anomalies

Presentation

Position

Multiple gestation

Fetal anomalies

Fit issues

Photo from www.fetalhydrocephalus.com/hydro/Default.aspx

Cephalic (Fetal head is presenting)

In addition, presentation can be classified

according to attitude of fetal head and

what is felt by the gloved fingers

Face/brow

Transverse lie

Breech

Maternal Risk: C-section

Fetal Risk: cord prolapse

Treatment:

External version

Conscious sedation: Versed and Fentanyl

Possible use of Terbutaline (Brethine)

C-section if version fails or fetus resumes

breech presentation

4% of term fetuses are breech

´Fetal position has a significant effect on

(the) likelihood of cesarean delivery forboth nulliparous and multiparous women

and this effect is modified by fetal weight.µ

Herrick et al, 2009

From: www.getdoe.com

You palpate a firm, round form in the fundus,

small parts on the woman¶s right side, and a

long, smooth, curved section on the left side.

Based on these findings, the nurse should anticipate auscultating

the fetal heart in which of the following?

Macrosomia (4000 grams)

Often leads to cephalopelvic

disproportion (CPD) Treatment?

17 lb 1 oz Russian baby

delivered by C-section

www.hoax-slayer.com/giant-Russian-baby.shtml

From: www.catalog.nucleusinc.com

Placenta Previa

Painless bleeding

PlacentalAbruption

Usually pain Thrombin - more contractions

Bleeding may be hidden

Constant and intermittent pain is possible

Assess location, rate pain, describe characteristics

Notify MD/DO ASAP Start IV

Hidden (Occult) Partial Complete

Call for help

Knee-chest or MODIFIED Trendelenburg

Sterile vaginal examination

No funic replacement

Digital displacement of little help

Avoid touching the cord

Bladder inflation works (if you anticipate adelay to deliver)

400 ² 700 mL (use non-dextrose IVF)

Start IV (If IV in, discontinue Pitocin, IVbolus)

STAY CALM!

If time, monitor the fetus and apply oxygen

Fig. 17-2

H ypotonic Uterine Contractions (Inertia) UCs become infrequent and palpate mild

Slow progress

Mechanical Dystocia?

Exhausted mother and uterus?

Infection?

Nursing :

If fetal well-being and low station, AROM

(provider) Oxytocin (Pitocin augmentation)

Ambulation does NOT work!

Hydrotherapy is nice but it is not the solution!

Functional Dystocia: due to powerproblems

Usually contractions are too few or

too weak, i.e., inadequate power

Nursing role: Notify the provider, document

your assessment of uterine activity

Induction: Initiating labor by artificial means

Mechanical or medications to ripen the cervix

Oxytocin (Pitocin) after the cervix is ripe

Augmentation:

Enhance weak and well-spaced contractions

UC every 2-3 min x 40-60 secondswith interval of at least 1 minute and

resting tone no greater than 25 mm Hg

Pitocin is NOT the solution for mechanical

problems

Fetal and Maternal Danger if:

Contractions

< q 2 minutes

90 or more seconds

Peak pressure > 90 mm Hg

Resting tone 30 or more mm Hg

FHR may not indicate severity of ischemiaRole of the Nurse:

Decrease or discontinue oxytocin infusion

TITR ATE DOWN or DISCONTINUE

Hypertonic Uterine ContractionsLatent Phase

Spontaneous Hyperstimulation

Usually mild, frequent, and related to anxiety and/orher bs

Nursing: antianxiety medication, IV bolus, warmbath, rest, pain control (Morphine sleep)

Latent Phase

Tachysystole d/t Exogenous Prostaglandins or Oxytocin

May be related to cocaine use

Active Phase

UCs too long , too close, too strong (MVUs),

resting tone too high

uteroplacental perfusion deficit precedes

fetal hypoxia, acidemia, acidosis, asphyxia

Fetal aspiration of meconium (not likelywithout fetal gasping after primary apnea,

hypotension, and bradycardia)

maternal pain (decrease or DC Pitocin)

Breakthrough pain (epidural ineffective)

Blood in the urine? Consider fetal-pelvic fit

and fetal position

Maternal Exhaustion, ineffective pushing

Hypertonic Uterine Contractions

POST PARTUM HEMORRHAGE

Blood loss of 500 mL or more

Especially if the uterus is infected after

A prolonged labor and/or

Excessive Pitocin administration

Mechanicaldystocia withinability of thefetus to passthrough themother·s pelvis

Maternalconditions where

pushing is harmful Active maternal

herpes or HIV

Previous surgery onthe uterus

Fetal compromise

Placenta previa orPlacental abruption

Twins: vtx/breech,or breech/vtx«

Scheduled, Urgent, Emergent

ScheduledScheduled: to preserve vaginal integrity,

repeat C-section, breech, twins, other

UrgentUrgent : fetal condition likely to deteriorate

(ASAP) Emergency (STAT)Emergency (STAT): no prep, no FoleyFoley,

just go to the OR now; may be under a local if anesthesia is not in house

Psychological impact: anxiety, PTSD

Feelings of dependency/lack of control

Offer support, remember the family,

especially if STAT C-section

Mother Anesthesia

Respiratorycomplications

Blood clots/DVT Injury to urinary tract

Delayed intestinalperistalsis/ileus

Infection

Hemorrhage Death

Neonate Inadvertent preterm

birth Respiratory problems

because of delayedabsorption of lungfluid

Injury

Range Category

BL 120-160 bpm 1 or Normal

Tachycardia

Moderate

Marked

> 160 bpm

161-180 bpm

2 - impending

decompensation

No atrial kick/ischemia and

injury risk

Bradycardia

Moderate

Marked

100-119 bpm

<100 bpm

2 or 3

Ischemia risk/low fetal BP

Accelerations 15 bpm for

15 or more seconds

With variability: 1/normal

Without variability: 3/NRDecelerations

Variable

Nadir depth from BL

10-40 bpm

5-60 bpm

10-60 bpm

Head/brain compression

Placenta: Hypoxia/Acidosis

Cord Compression

Discontinue oxytocin infusion

Reposition the patient (knee-chest is best,lateral is next best)

Oxygen at 10 L/minute by mask

IV bolus? (consider dangers) Myth: IV fluids to increase maternal volume

Fact: Release of atrial natriuretic peptide -a smooth muscle relaxant

Communicate: Charge nurse and CNM orMD/DO

SVE to check for a baby (vs. cord)

Consider route and timing of delivery

The End

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