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Transcript of Normal Labor. Critical Factors in Labor 5 critical factors Birth passage Fetus Relationship of...
Normal Labor
Critical Factors in Labor
5 critical factorsBirth passage
Fetus
Relationship of Maternal Pelvis and Presenting Part
Physiologic forces of labor
Psychosocial considerations
1 Birth Passage
Size of pelvis
Type of pelvisGynecoid
Android
Arthropoid
Platypelloid
Combination
1 Birth Passage
1 Birth Passage
Knowledge of the shape and dimensions of the normal female pelvis is essential for a proper understanding of the second stage of labour and its abnormalities since the body pelvis is an important component which determines the birth canal structureThe human female pelvis shows adaptations that are of obstetric advantage and relate also to the relative ldquobigrdquo head of the foetus These adaptations develop chiefly in childhood and puberty
1 Birth Passage
Pelvic bone is made up of various sections
For obstetrical purposes the pelvis is divided by the pelvic brim into two partsndash The False Pelvisndash The True Pelvis
1 Birth PassageThe False Pelvis is that portion above the pelvic brim It does not take part in the mechanism of delivery and is of no obstetric interest1048698 In the past attempts were made to form a judgement of the size of the true pelvis by measuring the width of the false pelvis The information thus obtained was often inaccurate
1048698 Intercristal diameter [IC ~29 cm] widest point on lateral aspect of iliac crest1048698 Interspinous diameter [IS ~26 cm] distance between the lateral tips of the anterior superior iliac spines1048698 External conjugate [AP] diameter [EC ~20 cm] distance between apex of spine of 5th lumbar vertebra and centre of the superior border of symphysis pubis
1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Critical Factors in Labor
5 critical factorsBirth passage
Fetus
Relationship of Maternal Pelvis and Presenting Part
Physiologic forces of labor
Psychosocial considerations
1 Birth Passage
Size of pelvis
Type of pelvisGynecoid
Android
Arthropoid
Platypelloid
Combination
1 Birth Passage
1 Birth Passage
Knowledge of the shape and dimensions of the normal female pelvis is essential for a proper understanding of the second stage of labour and its abnormalities since the body pelvis is an important component which determines the birth canal structureThe human female pelvis shows adaptations that are of obstetric advantage and relate also to the relative ldquobigrdquo head of the foetus These adaptations develop chiefly in childhood and puberty
1 Birth Passage
Pelvic bone is made up of various sections
For obstetrical purposes the pelvis is divided by the pelvic brim into two partsndash The False Pelvisndash The True Pelvis
1 Birth PassageThe False Pelvis is that portion above the pelvic brim It does not take part in the mechanism of delivery and is of no obstetric interest1048698 In the past attempts were made to form a judgement of the size of the true pelvis by measuring the width of the false pelvis The information thus obtained was often inaccurate
1048698 Intercristal diameter [IC ~29 cm] widest point on lateral aspect of iliac crest1048698 Interspinous diameter [IS ~26 cm] distance between the lateral tips of the anterior superior iliac spines1048698 External conjugate [AP] diameter [EC ~20 cm] distance between apex of spine of 5th lumbar vertebra and centre of the superior border of symphysis pubis
1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
1 Birth Passage
Size of pelvis
Type of pelvisGynecoid
Android
Arthropoid
Platypelloid
Combination
1 Birth Passage
1 Birth Passage
Knowledge of the shape and dimensions of the normal female pelvis is essential for a proper understanding of the second stage of labour and its abnormalities since the body pelvis is an important component which determines the birth canal structureThe human female pelvis shows adaptations that are of obstetric advantage and relate also to the relative ldquobigrdquo head of the foetus These adaptations develop chiefly in childhood and puberty
1 Birth Passage
Pelvic bone is made up of various sections
For obstetrical purposes the pelvis is divided by the pelvic brim into two partsndash The False Pelvisndash The True Pelvis
1 Birth PassageThe False Pelvis is that portion above the pelvic brim It does not take part in the mechanism of delivery and is of no obstetric interest1048698 In the past attempts were made to form a judgement of the size of the true pelvis by measuring the width of the false pelvis The information thus obtained was often inaccurate
1048698 Intercristal diameter [IC ~29 cm] widest point on lateral aspect of iliac crest1048698 Interspinous diameter [IS ~26 cm] distance between the lateral tips of the anterior superior iliac spines1048698 External conjugate [AP] diameter [EC ~20 cm] distance between apex of spine of 5th lumbar vertebra and centre of the superior border of symphysis pubis
1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth Passage
1 Birth Passage
Knowledge of the shape and dimensions of the normal female pelvis is essential for a proper understanding of the second stage of labour and its abnormalities since the body pelvis is an important component which determines the birth canal structureThe human female pelvis shows adaptations that are of obstetric advantage and relate also to the relative ldquobigrdquo head of the foetus These adaptations develop chiefly in childhood and puberty
1 Birth Passage
Pelvic bone is made up of various sections
For obstetrical purposes the pelvis is divided by the pelvic brim into two partsndash The False Pelvisndash The True Pelvis
1 Birth PassageThe False Pelvis is that portion above the pelvic brim It does not take part in the mechanism of delivery and is of no obstetric interest1048698 In the past attempts were made to form a judgement of the size of the true pelvis by measuring the width of the false pelvis The information thus obtained was often inaccurate
1048698 Intercristal diameter [IC ~29 cm] widest point on lateral aspect of iliac crest1048698 Interspinous diameter [IS ~26 cm] distance between the lateral tips of the anterior superior iliac spines1048698 External conjugate [AP] diameter [EC ~20 cm] distance between apex of spine of 5th lumbar vertebra and centre of the superior border of symphysis pubis
1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth Passage
Knowledge of the shape and dimensions of the normal female pelvis is essential for a proper understanding of the second stage of labour and its abnormalities since the body pelvis is an important component which determines the birth canal structureThe human female pelvis shows adaptations that are of obstetric advantage and relate also to the relative ldquobigrdquo head of the foetus These adaptations develop chiefly in childhood and puberty
1 Birth Passage
Pelvic bone is made up of various sections
For obstetrical purposes the pelvis is divided by the pelvic brim into two partsndash The False Pelvisndash The True Pelvis
1 Birth PassageThe False Pelvis is that portion above the pelvic brim It does not take part in the mechanism of delivery and is of no obstetric interest1048698 In the past attempts were made to form a judgement of the size of the true pelvis by measuring the width of the false pelvis The information thus obtained was often inaccurate
1048698 Intercristal diameter [IC ~29 cm] widest point on lateral aspect of iliac crest1048698 Interspinous diameter [IS ~26 cm] distance between the lateral tips of the anterior superior iliac spines1048698 External conjugate [AP] diameter [EC ~20 cm] distance between apex of spine of 5th lumbar vertebra and centre of the superior border of symphysis pubis
1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth Passage
Pelvic bone is made up of various sections
For obstetrical purposes the pelvis is divided by the pelvic brim into two partsndash The False Pelvisndash The True Pelvis
1 Birth PassageThe False Pelvis is that portion above the pelvic brim It does not take part in the mechanism of delivery and is of no obstetric interest1048698 In the past attempts were made to form a judgement of the size of the true pelvis by measuring the width of the false pelvis The information thus obtained was often inaccurate
1048698 Intercristal diameter [IC ~29 cm] widest point on lateral aspect of iliac crest1048698 Interspinous diameter [IS ~26 cm] distance between the lateral tips of the anterior superior iliac spines1048698 External conjugate [AP] diameter [EC ~20 cm] distance between apex of spine of 5th lumbar vertebra and centre of the superior border of symphysis pubis
1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth PassageThe False Pelvis is that portion above the pelvic brim It does not take part in the mechanism of delivery and is of no obstetric interest1048698 In the past attempts were made to form a judgement of the size of the true pelvis by measuring the width of the false pelvis The information thus obtained was often inaccurate
1048698 Intercristal diameter [IC ~29 cm] widest point on lateral aspect of iliac crest1048698 Interspinous diameter [IS ~26 cm] distance between the lateral tips of the anterior superior iliac spines1048698 External conjugate [AP] diameter [EC ~20 cm] distance between apex of spine of 5th lumbar vertebra and centre of the superior border of symphysis pubis
1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth PassageThe True Pelvis is that portion below the pelvic brim It determines the size and shape of the birth canal
Brim formed by the upper margins of pubic bones the ilio-pectineal lines and the anterior upper margin of the sacrumCavity formed by the pubicbones ischium ilium andsacrumOutlet diamond-shapedmade up of the pubic bonesischium ischial tuberositiessacrotuberous ligament and5th segment of sacrum
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
1 Birth Passage
brim Cavity Outlet
Transverse 131 125 118
Oblique 125 131 118
Anteroposterior
113 131 125
1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth Passage
Four different types of pelvises but frequently mixed types
gynaecoidanthrapoid android
platypelloid
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Pelvic inletsGynecoid
Platypoid
Anthropoid Android
1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth PassageGynaecoid pelvisIdeal pelvis favouring a normal delivery 506 of women
transversely but almost rounded1048698 Sacrum curved1048698 Ischial spines not prominent1048698 Short-cone pelvis1048698 Obtuse greater sciatic notch1048698 Triangular obturator foramen1048698 Sub-pubic arch rounded [Roman arch] angle at least
1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth PassageAndroid pelvis1048698 Male-type pelvis favouring OP positions and apt to cause deep transverse arrest of head 224 of women
Brim heart-shaped1048698 Sacrum curved1048698 Ischial spines prominent1048698 Long-cone funnel pelvis1048698 Acute greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch very narrow [Gothic arch]
1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth PassageAnthrapoid pelvis1048698 Ape-like pelvis favouring OP positions often requiring operative vaginal deliveries 227 of women
Brim AP oval1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Long-cone funnel pelviswith straight sidewalls1048698 Obtuse greater sciatic notch1048698 Oval obturator foramen1048698 Sub-pubic arch narrow
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
1 Birth PassagePlatypelloid pelvis1048698 Often leads to cephalo-pelvic disproportion 44 of women
Brim oval transversely1048698 Sacrum very slightly curved1048698 Ischial spines prominent1048698 Short-cone shallow pelvis1048698 Acute greater sciatic notch1048698 Triangular obturatorforamen1048698 Wide arch narrow
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
1 Birth PassageAsymmetrical pelvises
Abnormality of lower limbAbnormality of pelvic girdleAbnormality of vertebral column
Robertrsquos pelvisOsteomalacic pelvis
Scoliotic pelvisCoxalgic pelvis
Split pelvis Naegelersquos pelvis
1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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1 Birth Passage
Measurement of AP conjugatesbullDiagonal conjugate ~120 cmbullTrue conjugate ~110 cmbullAP outlet ~125 cm
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
1 Birth Passage
Assess shape of sacrum
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
2 Fetus
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
2 FetusFetal head
Largest and least flexible
Bones of the base of the cranium are fixed vault (frontal parietal occipital) are not
Molding
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
2 FetusSutures
Frontal
Sagittal
Coronal
Lambdoidal
Frontal suture
Sagittal suture
Coronal suture
Lambdoidal suture
Note sutures are actually membranous spaces that meet at fontanels
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
1 Bones 2 parietals 2 frontals 2 temporals occipital2 Sutures sagital frontal lamboidal coronal temporal3 Fontanelles anterior posterior 2 anterior temporals 2 posterior temporals
Foetal skull
Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal skull
1 Suboccipitobregamatic ~95 cc Vertex2 Suboccipitofrontal ~100 cm Sinciput3 Occipitofrontal~1124 cm persistent OP4 Mentovertical ~138 cm brow5 Submentobregmatic ~95 cm Face6 Submentovertical ~1125 cm incompletelyextended face7 Biparietal diameter ~95 cm
1
2
3
5
6
7
4
Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fontanelles intersection of sutures allows for molding helps identify position of head
Anterior (bregma)Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
PosteriorTriangle shaped
Smaller
Closes in 8-12 weeks
Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Other landmarks on the fetal headMentum
Sinciput
Vertex
occiput
Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fetal attitudeRelation of fetal parts to one anotherNormal mod flexion of head flexion of arms onto chest flexion of legs onto abdomen
Changes in attitude can contribute to longer more difficult labor or Cesarean Section
Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fetal lieRelationship of the spine (cephalocaudal axis) of the fetus to the spine of the mom
Longitudinal parallel
Transverse right angle
Oblique acute abgle
Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus Fetal lie
Longitudinal
Transverse
Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fetal presentationBody part entering the pelvis (presenting part)
Cephalic
Breech
Shoulder
Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus Fetal lie
Cephalic
Shoulder
Breech
Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fetal presentation Cephalic
Vertex presentationMost common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fetal presentation CephalicMilitary presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fetal presentation Cephalic
Brow presentationFetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetus
Fetal presentation Cephalic
Face presentationHead hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal presentations
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
FetusFetal presentation Breech
Sacrum is the landmark
Complete breechKnees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)
Buttocks and feet are presenting parts
FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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FetusFetal presentation Breech
Sacrum is the landmark
Frank breechHips flexed knees extended
Buttocks is presenting part
FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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FetusFetal presentation Breech
Sacrum is the landmark
Footling breechHips and legs extended
Feet are presenting parts (single vs double)
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
FetusFetal presentation Shoulder
Acromion process of shoulder is presenting part
3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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3 Relationship of maternal pelvis and presenting
part
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Relationship of maternal pelvis and presenting part
EngagementLargest diameter of presenting part reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in primigravida anytime for multigravida
When vertex presentation biparietal diametr is largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Relationship of maternal pelvis and presenting part
StationRelationship of presenting part to imaginary line drawn between ischial spines of pelvis (0 station)Measured cm above (+) or below ischial spines (-)Some use +3 to -3 some use +5 to -5In normal pelvis narrowest diameter through which fetus passes is failure to descend
Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Station
Station of the head inrelation to ischial spines
1048698In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048698In Anthropoid pelvis distance is ~7 cm1048698In Platypelloid pelvis distance is ~3 cm
Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Relationship of maternal pelvis and presenting part
Fetal positionRelationship of the landmark on the presenting part to the anterior (A) posterior (P) or transverse (T) side of the maternal pelvis3 notations
R (right) or L (left)Landmark O (occiput) M (mentum) S (Sacrum)Where landmark A (anterior) P (posterior) T (transverse)
Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Relationship of maternal pelvis and presenting part
Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Relationship of maternal pelvis and presenting part
OA most common easiest to deliver
Other positions are considered malpositions
Position influences labor and birth
Largest diameter in posterior position back pain longer 2nd stage
Can tell position by palpation of abdomen and Vaginal Examination
4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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4 Physiologic forces of labor
Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Normal uterine action
1048698 At term uterus is ~30 cm in length and weighs ~1 kg
1048698 Muscle fibres have increased greatly in size ndash each fibre being ~10x its original size
1048698 The muscle fibres run in various directions and interlace everywhere some run circularly some longitudinally majority run obliquely
Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Normal uterine action
ldquoPacemakerrdquo point near terine cornu1048698 Gradient pattern of contractibility with fundal dominance1048698 Retraction of upper segment and thinning of lower segment1048698 Physiological Retraction Ring
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Physiologic forces of labor
Primary uterine muscles (causes dilation and effacement)
Secondary abdominal muscles (for 2nd stage)
Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiologic forces of labor
Phases of contractionsIncrement
Acme
Decrement
RelaxationUterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiologic forces of labor
Frequency
Duration
Intensity
Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiologic forces of labor
1048698 Aim at- strong amp regular contractions1048698 ASSESS DURATION OF CONTRACTIONndash mild moderate strongndash lt20 sec 20-40 sec gt40 sec1048698 ASSESS FREQUENCY OF CONTRATIONSndash Number of contractions in last 10 min of each hrndash increased frequency from 110 to 510 minutes1048698 ASSESSMENT CAN BE CARRIED OUTndash Clinically by palpationndash External tocographyndash Internal uterine pressure measurement
Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiologic forces of labor
Intensity
indirect (subjective) palpation mild moderate strong
direct (objective) mmHg pressure with IUPC (intauterine)
Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiologic forces of labor
Early labor mild short duration irregular
As labor progresses stronger longer more regular closer together
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Physiologic forces of labor
Bearing down (Pushing)
must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Psychosocial Considerations
Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiology of Labor
What causes labor Unknown but hypotheses
Progesterone withdrawalEnd of pregnancy there is a decrease in availability of progesterone to myometrial cells
ProstaglandinsInitiation of labor can be demonstrated with prostaglandins and preterm labour (PTL) can be stopped with antiprostaglandins
Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiology of LaborWhat causes labor Unknown but hypotheses
Corticotropin-releasing hormone (CRH)CRH increases during pregnancy with sharp increase at term
CRH is increased in PTL
CRH is increased in multiple gestations
CRH is known to stimulate synthesis of prostaglandin F to E
FetalSecretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiology of LaborMyometrial activity
Divides into 2 portions physiologic retraction ring
Upper becomes thicker (contractile part) lower become thinner (passive part)
With each contraction muscles of upper uterine segment shorter and exert longitudinal traction of the cervix effacement
Effacement recorded as
Primiparous usually precedes dilation multiparous usually after dilation
Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiology of LaborMyometrial activity
With each contraction uterus elongates decreasing horizontal diameter
Causes a straightening of the fetal body pushing the presenting part toward the lower uterine segment and the cervix
As uterus elongates long muscle fibers are pulled over presenting part dilatation
Recorded in cm (closed fingertip to 10)
Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Physiology of LaborMuscular change in the pelvic floor
Levator ani muscle and fascia of the pelvis draw rectum and vagina upward
As presenting part descends causes perineum to thin out (5cm paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Premonitory signs of Labor
Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plugBloody show
ROM (rupture of membrane)
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Premonitory signs of Labor
Note on ROMIf ROM at home told to come in
In term pregnancy ~80 will go into spontaneous labor will induce 24 hours if no labor will induce 12 hours will induce
SROM (spontaneous) vs AROM (antepartal)
Problem if ROM before engagementProlapsed cord
Problem if ROM before laborinfection
True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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True vs False LaborTrue False
Contractions
Regular uarrfrequency duration intensity
Irregular short duration mild
Pain Starts in back radiates to front
Begins in abdomen
Cervix change
Dilationeffacement No change
Cont change
Does not decrease with rest or warm bath walking makes stronger
Decreases with rest warm bath walking slows
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Stages of Labor
Stage 1Onset of regular contractions to complete dilatation
Stage 2Complete dilatation to birth
Stage 3Birth of infant to birth of placenta
Stage 4Birth of placenta to 1-4 hrs recovery
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Stages of Labor Stage 1 divided into 3 phases
1 Latent phase 0-3 cmPrimip 86 hrs
Multip 53 hrs
May have irregular contractions short mild ndash moderate
Excited talkative smiling
2 Active phase 4-7 cmPrimip 46 hrs dilation at least 12 cmhr
Multip 24 dilation at least 15 cmhr
Uterus contraction through 2-5 min by 40-60 sec mod ndash strong
uarr anxiety sense of hopelessness fear of loss of control
Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Stages of Labor Stage 1 divided into 3 phases conthellip
3 Transition phase 8-10 cmPrimip 36 hrs
Multip variable
Uterus contraction through 1 frac12 - 2 min 60-90 sec mod ndash strong
Acutely aware of intensity of uterus contraction significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive
As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Partogram
Alert line
Acton line
Normal dilatation
Abnormal dilatation
Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Stages of Labor 2nd stage
Usually lt2 hrs (less in multips)Affected by epidural maternal pushing position of presenting part size of pelvis
As head approaches perineum labia separate may see presenting part with pushing then recede Rectum bulges and flattens
Crowning
Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Stages of Labor Positional changes of the fetus
Descent- enters OP or obliqueFlexion- resistanceInternal rotation- to fit narrowest diameterExtension- extends as it comes under symphysisRestitution- shoulders still oblique neck twisted Once head is free turns to one side and aligns with shouldersExternal rotation- as shoulders rotate head is turned farther to one sideExpulsion- shoulders slip under symphysis then body
Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Stages of
Labor
Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Stages of Labor
Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Stages of Labor 3rd stage
Usually will induced 5 mins May be up to 30 mins Retained after 30 mins
Signs of separationGlobular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina
Shiny schultze
Dirty duncan
Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Stages of Labor 4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes darr BP uarr pulse pressure tachycardia
Uterus contracted and midline ~12 way between symphysis and umbilicus Within 1st hour about level with umbilicus
Shaking hunger thirst
Bladder is hypotonic
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Maternal Systemic Response to Labor
Cardiovascular SystemWith strong uterus contraction stops or severely impedes blood flow to uterus redistribution of 300-500 mL of blood to peripheral circ and uarr in peripheral resistance uarr BP darr pulse uarr CO by ~ 30
When lying supine CO SV BP and pulse uarr (Pushing also)
Immediately after birth CO peaks at 80 uarr over pre-labor then darrs over 1st hour Still has elevation for ~ 24 hrs
Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Maternal Systemic Response to Labor
BPRises during 1st and 2nd stage
Fluid and electrolyte balanceInsensible water loss from sweating hyperventilation
Resp systemuarr O2 demand and consumption
Hyperventilation darrPaCO2 and resp alkalosis
Acid base balance levels return to preg levels by ~24 hrs to norm wi few weeks
Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Maternal Systemic Response to Labor
Renaluarr maternal renin renin activity and angiotensinogenPolyuria is commonMay have some hematuria
GI Gastric emptying time prolongedAt risk if surgery neededFluids generally OK
Blood valuesWBCs increased to 25-30000darr glucose
Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Response to Labor
FHR changes can cause decelerationsAcid-Base darr pH uarr PaCO2 darr PO2 uarr base deficitHemodynamic fetal and placental reserves carry fetus thru anoxic periodsBehavioral states sleepawake statesFetal sensation sensitive to light sound touch
Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Intrapartal Nursing Assessment
Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Maternal Assessment
HistoryObtained from mom and record
Include culture educational needs support
Intrapartal High Risk ScreeningExcessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Maternal Assessment
Intrapartal physical and psychosocial assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors hosp policy
Always vital signs labor status fetal status
Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Maternal Assessment
PhysicalVS BP le 14090 pulse 60-90 resp 14-22 pulse ox gt 95
Wt 25-35 normal slightly more for underweight 15-25 overweight
Lungs clear norm breath sounds
Fundus just below xiphoid process
Edema slight
Skin and mucous membranes norm turgor smooth pink moist
Perineum tissues smooth pink may be blood tinged
Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Maternal Assessment
Labor statusRegular contractionsMembranes ROM color odorCervix progressive dilationeffacement fetal descent
Fetal statusFHR 110-160PresentationPositionActivity
Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Methods of Evaluating Labor Progress
ContractionsPalpation fundus mild mod strong
Electronic externalUses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Methods of Evaluating Labor Progress
ContractionsElectronic external
Advantagesndash Used on anyonendash Non-invasivendash Can be used intermittently
Disadvantagesndash No intensity measurementndash Dependent upon women to remain fairly stillndash Belt uncomfortablendash Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Methods of Evaluating Labor Progress
ContractionsElectronic internal
Uses IUPC
Advantagesndash Accurately measures freq duration intensity resting
tonendash Can use for amnioinfusion
Disadvantagendash ROM must have occurred
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Methods of Evaluating Labor Progress
Cervical AssessmentVaginal Examination dilation effacement station presentation position membrane status
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Methods of Evaluating Fetal Status
Determination of Position and Presentation
Inspection of abd
Palpation of abd
VE
US
Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Methods of Evaluating Fetal Status
Inspection of abdIs the uterus longitudinal or transverse
VE
US (Ultrasound)
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Methods of Evaluating Fetal Status
Palpation of abdLeopoldrsquos maneuver
1st maneuverndash What is in fundusndash Head is firm round moves independently of trunk
buttocks is softer symmetric moves with trunk
2nd maneuverndash Where is the fetal back locatedndash Back is firm smooth hands and feet are irregular
3rd maneuverndash What is above the inlet (what presentation)
4th maneuverndash Where is the brow and back of head (what position)
Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Methods of Evaluating Fetal Status
Auscultation of FHRFetoscope doppler EFM (electrpfetomonitor)
Heart tones heard best thru fetal backOA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before during and after contraction
Intermittent monitoring has been found to be just as effective as continuous for low risk Hosp policy determines who when how often
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring ExternalUS transducer (sound waves)
Uses gel
AdvantageContinuous observation of FHTs
DisadvantageMay be difficult to trace if baby active mom moving obesehydramniosmult gest
Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Methods of Evaluating Fetal Status
Electronic Fetal Monitoring InternalUse of spiral electrode attached to fetal head or buttocks
Not applied to face sutures fontanels perineum cervix
AdvantageAccurate heart rate tracing
DisadvantageMust have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern Interpretation
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE
Significance of fetal monitor strip
Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern
DefinitionsBaseline FHR between UC for 10 mins (doesnrsquot include rate during contraction) Normal term 110-160Tachycardia gt160 for gt10 minBradycardia lt110 for gt10 minAcceleration transient increases in FHR above baseline for lt 10 minDeceleration transient decrease in FHR from baseline for lt 2 minProlonged deceleration decrease in FHR from baseline for 2-10 min
Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern
BaselineTachycardia gt160 for gt10 min
Causes ndash early fetal hypoxiandash Maternal feverndash Betasympathomimetic drugsndash Dehydration
Non-reassuring if associated with other signs or if pathologic
Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern
BaselineBradycardia lt110 for gt10 min
Causesndash Maternal hypotensionndash Prolonged umbilical cord compressionndash Fetal asphyxia ndash profoundndash Fetal heart block
Non-reassuring signTx correct cause
ndash Position changendash uarr fluidndash O2ndash dc pitocinndash Delivery ()
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Fetal Heart Rate Pattern
Variability Interplay between sympathetic and parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-term)
Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern
Variability Long term variability
Rhythmic fluctuations of FHR difference between lowest and highest FHRDecreased lt6 BPMModavg 6-25 BPMMarked (saltatory) gt25 BPM
Short-term variabilityDifference between successive heartbeats as measured by R-R wavesPresent or absentOnly measured with internal electrodeIndicator of fetal oxygen reserve
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Fetal Heart Rate Pattern
Variability Sinusoidal
Indulating pattern with no short-term variability or accels
Ominous sign
PsuedosinusoidalAssociated with med use
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Fetal Heart Rate Pattern
Accelerations15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
- Slide 1
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-
Fetal Heart Rate Pattern
Early DecelerationsAssociated with head compressionWaveform consistently uniformMirrors contractionsOnset is just before or early in contractionLowest level consistently at or before midpoint of contractionRange usually within 110-160Can be single or repetitiveBenign or reassuringMost often seen in 2nd or 3rd phaseTreatment
NONE
Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern
Late DecelerationsAssociated with uteroplacental insufficiency resulting in hypoxemia
Waveforms uniform shape reflects contractions
Onset is late in contraction and lowest level consistently after midpoint of cont (Depth not indicative of threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern
Late Decelerations (continued)Can occur occasional consistent gradually increasing repetitive
May be caused by pathologic (myocardial depression calcified placenta abruption) or physiologic (supine hypotension tetanic contractions)
Non-reassuring
Tx correct causePosition change O2uarr fluid dc pitocin
Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Fetal Heart Rate Pattern
Variable DecelerationsAssociated with cord compression
Varies in onset duration intensity and waveform
Generally drops and returns abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx correct causeVE to ro prolapsed cord O2Position change dc pitocinuarr fluid
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Fetal Heart Rate Pattern
Prolonged DecelerationsCan be non-reassuring or benign depending upon variability and if returns to baseline
Tx correct causePosition change
uarr fluid
O2dc pitocin
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Evaluation of FHR tracings
Resting tone
Uterus contraction freq duration intensity
Baseline FHR normal
Variability STV (short-term) and LTV (long-term)
Changes from baseline accels decels
Reassuring or non-reassuring
Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Evaluation of FHR tracings
ReassuringWithin normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
- Slide 1
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-
Evaluation of FHR tracings
Non-ReassuringNot within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
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Other methods of fetal assessment
Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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The Family in Childbirth Needs and Care
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
- Slide 1
- Slide 2
- Slide 3
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-
When do I go to the hospital
ROM
Regular frequent contractions (primip q 5min for 1 hr miltip q 6-8 min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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What is going to happen to me when I arrive
History
Physical
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
LatentVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 30 min ndash 1 hr
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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- Slide 2
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- Slide 156
- Slide 157
-
Assessment during 1st StageNOTE general standards individualized
for patient status and hospital policy
ActiveVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Assessment during 1st StageNOTE general standards individualized for
patient status and hospital policy
TransitionVS q 1 hr temp q 4 hrs unless ROM then q 1-2 hrs
UC status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
- Slide 1
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Comfort during 1st stage
Ambulation Rocking Chair
Position changes knee chest sitting side-lying birthing ball birthing bar
Personal CareBath shower
Empty bladder
Po fluids vaseline to lips
Perineal care
Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Comfort during 1st stage
AnxietyKeep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Comfort during 1st stage
Supportive Relaxation TechniquesDistraction
TouchEfflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
- Slide 1
- Slide 2
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-
Comfort during 1st stageBreathing Techniques
Pattern-paced breathingCleansing breath
Slow
Moderate
Pattern
Hyperventilation tingling numbness in nose mouth lips fingers toes spots before eyes
Tx encourage to slow down breathing paper bag
Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Care during 2nd stageVS q 15 ndash 30 min
UC status q 15 ndash 30 min
Fetal heart rate status (low risk) q 15 min
(high risk) q 5 min
ComfortCool cloths
Fanning
Fluids
Support
Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Care during 2nd stagePushing positions
SideSquattingSittingKnee-chestTowel pullBed bars
Perineal AssistanceWarm compressesPerineal massagerest
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Care during 2nd stagePreparing for Delivery
Perineal prepBetadine Hibiclens soap and water
Procedure
StirrupsPadded
Adjusted (no pressure on back of calves or knees)
Legs in and out together
Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Care during 2nd stagePositions for delivery
LitotomyAdvantages
ndash assessment of FHTsndash Performance and repair of episiotomy
Disadvantagesndash Many
LateralAdvantages
ndash More comfortablendash No venous compromisendash Less pressure on neck
Disadvantagesndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Care during 2nd stagePositions for delivery
SquattingSittingAdvantages
ndash Increases pelvic outletndash Helps pushing effortsndash Uses gravity
Disadvantagesndash Perineum relatively inaccessiblendash FHT monitoring difficultndash Performance and repair of episiotomyndash Inability to use assistive devices
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Care during 2nd stagePositions for delivery
Hands and kneesAdvantages
ndash Less pressure on perineumndash Increases pelvic diameterndash Increased placental flow
Disadvantagesndash Increased fatiguendash Decreased eye contact between pt and caregiverndash Inability to use assistive devices
Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Care during 2nd stageDelivery of Head
Check for nuchal cordSuction mouth and nose
Delivery of ShouldersRelease of anterior shoulderRelease of posterior shoulder
Delivery of BabyMouthnose suctionPlaced on momrsquos abdCord clamped and cut
Held level with vagina to prevent lossexcess blood fromto babyCheck for 3 vessels
Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Care during 3rd stageObserve for signs of placental separationTo aid in delivery
Bear downGentle traction on cordFundal pressureManual removal
Inspection of placentaInspection of cervixperineumPalpationMassage of fundusOxytoxics
Given IV or IM after placental deliveryPrevents uterine atony and excessive bleeding
Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Nursing Care During 4th Stage of Labor
Vs uterus bleeding q 15 min x 1 hr
Uterus U firm midline
Lochia rubra small-mod
Bladder atonic fills rapidly can displace uterus usually to Right uterine atony
Perineum no hematoma some swelling ice
Shaking tired hungry thirsty
Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Nursing Care During Precipitous Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm confident
Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Pain Management During Labor
The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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The What Whens and Hows of Pain Management
Pain in 1st stageDilatation of cervixHypoxia of myometrial cellsStretching of lower uterine segmentPressure on adjacent structures
Pain in 2nd stageHypoxia of myometrial cellsDistention of vagina and perineumPressure on adjacent structures
Pain in 3rd stageUterine contractionsCervical dilatation
The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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The What Whens and Hows of Pain Management
Factors affecting response to painPreparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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The What Whens and Hows of Pain Management
40-45 receive epidural anesthesia
35-40 receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Systemic Analgesics
Maintaining normal vital signs and homeostasis are important because they affect fetal well-being
All systemic meds cross placental barrierFetal liver and kidneys are inadequate to metabolize agents
Blood-brain barrier is more permeable at time of birth
of blood volume flowing to brain uarrs during uterine stress so hypoxic fetus gets larger amt of depressant drug
Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Systemic Analgesics
Administration is usually when labor well established and maternal and fetal assessment within normal parameters
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Systemic Analgesics
NarcoticsButorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol 7x more potent than Morphine
Reverses analgesic effects of other opiods or narcotics and precipitates withdrawal in drug dependent women
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Systemic Analgesics
NarcoticsNalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
MeperidineNarcotic agonist
Usual dose 25 ndash 100mg
nv big problem
Resp depression in mom and baby
Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Systemic Analgesics
Opiate AntagonistNaloxone
Reverses depression and sedation from small doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice when depressant is unknown because it will not cause further depression
Resp depression can recur as it wears off
Dosage is wt based can be given to mom or baby
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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-
Systemic Sedatives
H1 receptor antagonistsSedatives anti-emetics narcotic potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Regional Analgesia and Anesthesia
Regional AnesthesiaTemporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that brings the agent into direct contact with the nervous system
Epidural
Spinal
Combination
Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Regional Analgesia and AnesthesiaLumbar epidural block
Local anesthetic injected into epidural spaceCan be intermittent or continuousPain sensation vs motor sensationUsually given when labor well establishedAdv
Good analgesiaFully awakePositive birth expMother can rest
DisadvMaternal hypotensionRequires skilled persons to administer and manageMay have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Regional Analgesia and Anesthesia
Lumbar epidural blockIV bolusPositionedInsertionCare after placementAdverse effects
Hypotensionndash Uterine displacementndash IV fluids increasedndash O2ndash Ephedrine
Inadequate anesthesiaPruritisSlight temp elevation
Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Regional Analgesia and Anesthesia
Spinal BlockFor CSAnesthetic agent injected into subarachnoid spaceImmediately positioned after injectionAnesthesia is almost immediateNo direct effect on fetusComplications
HypotensionDrug reactionSpinal headache (controversial) TreatmentTotal spinal block
Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Local Anesthesia
Pudendal BlockAnesthesia into area of pudendal nerve
Perineal anesthesia
LocalAnesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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General Anesthesia
May be needed for emergency
Not used as often for non-emergency surgery
ComplicationsFetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp system
Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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Analgesic and Anesthetic Considerations for High Risk
PTLFetus more susceptibleEpidural preferred
PreeclampsiaEpidural preferred if hematology studies OK
DMEpidural OkWatch closely for hypotension
CardiacEpidural with forceps
Bleedingepiduralgeneral
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