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• KEY FACTORS RELATED TO PROGRESS OF LABOR• FORCES OF LABOR• INTRAPARTAL ASSESSMENT AND
CARE OF MOTHER AND FETUS• CARE OF MOTHER AND INFANT IN
LABOR, DELIVERY, AND IMMEDIATE POST PARTUM• BIRTH RELATED PROCEDURES
KEY FACTORS RELATED TO PROGRESS OF LABOR
• PASSAGEWAY (BIRTH CANAL)• PASSENGER (FETUS)• POSITION OF THE MOTHER AND FETUS• PHYSIOLOGICAL FORCES OF LABOR• PSYCHOSOCIAL CONSIDERATIONS
BIRTH PASSAGE
• SIZE OF PELVIS• TYPE OF PELVIS• CERVICAL DILATATION, EFFACEMENT• ABILITY OF VAGINA AND INTROITUS TO
EXPAND
BIRTH PASSAGE
CERVICAL DILATATION AND EFFACEMENT
• DILATATION—MEASURED IN CENTIMETERS FROM 0 TO 10–0 CM—CERIVX CLOSED–10 CM—FULL DILATATION
• EFFACEMENT—MEASURED IN PERCENTAGE 0 TO 100%
Figure 15–11a Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.
Figure 15–11b Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.
Figure 15–11c Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.
UTERINE AND CERVICAL CHANGES
• UPPER UTERINE SEGMENT THICKENS AND PULLS UP
• LOWER SEGMENT EXPANDS AND THINS OUT• EFFACEMENT• CAUSES OF UTERINE CHANGES– ESTROGEN STIMULATES MUSCLE CONTRACTIONS– COLLAGEN IN CERVIX BROKEN DOWN– INCREASED WATER CONTENT OF THE CERVIX
• FETUS (PASSENGER)–SIZE OF FETAL HEAD–FETAL ATTITUDE–FETAL LIE–FETAL PRESENTATION–IMPLANTATION SITE OF
PLACENTA
PASSENGER
LANDMARKS OF FETAL SKULL• MENTUM• SINCIPUT• ANTERIOR FONTANELLE (BREGMA)• VERTEX• POSTERIOR FONTANELLE• OCCIPUT
Figure 15–4a Typical anteroposterior diameters of the fetal skull. When the vertex of the fetus presents and the fetal head is flexed with the chin on the chest, the smallest anteroposterior diameter (suboccipitobregmatic) enters the birth canal.
Figure 15–6a Cephalic presentation. Vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to present to the pelvis.
Figure 15–6c Brow presentation. The fetal head is in partial (halfway) extension. The occipitomental diameter, which is the largest diameter of the fetal head, presents to the pelvis.
PASSENGER
FETAL LIE AND PRESENTATION• FETAL LIE-- Relation of long axis of fetus
to long axis of the mother–Longitudinal–Transverse
• FETAL PRESENTATION—the body part of the fetus that first enters the pelvis
PASSENGER (PRESENTATION)
CEPHALIC PRESENTATION (95%)• VERTEX—SUBOCCIPTOBREGMATIC
• MILITARY--OCCIPITOFRONTAL
• BROW--OCCIPITOMENTAL
• FACE--SUBMENTOBREGMATIC
PASSENGER (PRESENTATION)
BREECH PRESENTATION (3%)• COMPLETE—HIPS FLEXED, KNEES FLEXED• FRANK—HIPS FLEXED, KNEES EXTENDED• FOOTLING—HIPS & FEET EXTENDED,
FEET,FOOT PRESENT TO MATERNAL PELVIS• KNEELING—HIPS EXTENDED, KNEES FLEXED
PASSENGER (PRESENTATION)
SHOULDER (TRANSVERSE) PRESENTATION (2%)
• TRANSVERSE LIE—SHOULDER IS USUAL PRESENTING PART
• COMPOUND—USUALLY ARM OR HAND PRESENTING ALONG PRESENTING PART
POSITION OF FETUS IN RELATION TO MOTHER’S PELVIS
ENGAGEMENT• WHEN THE WIDEST DIAMETER OF THE
PRESENTING PART HAS REACHED OR PASSED THE PELVIC INLET
• ENGAGEMENT USUALLY CORRESPONDS TO O STATION
• FLOATING—WHEN PRESENTING PART IS ENTIRELY OUT OF THE PELVIS AND FREELY MOVABLE IN THE INLET
Figure 15–8 Measuring the station of the fetal head while it is descending. In this view the station is 22/23.
POSITION
STATION• RELATIONSHIP OF FETAL PRESENTING
PART TO THE LEVEL OF THE ISCHIAL SPINES–THE ISCHIAL SPINES ARE O STATION–ABOVE THE SPINES IS A NEGATIVE VALUE–BELOW THE SPINES IS A POSITIVE VALUE
PHYSIOLOGIC FORCES OF LABOR–CONTRACTION PHASES---INCREMENT,
ACME, DECREMENT–DESCRIBED WITH FREQUENCY,
DURATION, AND INTENSITYPRIMARY AND SECONDARY FORCES OF
LABOREFFECTIVENESS OF PUSHINGDURATION OF LABOR
SIGNS OF LABOR• LIGHTENING• “BRAXTON HICKS” CONTRACTIONS• CERVIAL CHANGES• BLOODY SHOW• RUPTURE OF MEMBRANES• SUDDEN BURST OF ENERGY• WEIGHT LOSS• N&V, DIARRHEA, BACKACHE
TRUE LABOR/FALSE LABOR
• TRUE• CONTRACTIONS
REGULAR, INCREASE IN DURATION & STRENGTH
• INTERVAL SHORTENS• DILATATION &
EFFACEMENT PROGRESS
• INTENSITY INCREASES WITH WALKING
• FALSE• CONTRACTIONS
IRREGULAR, NO CHANGE IN DURATION, STRENGTH
• INTERVAL IRREGULAR OR NO CHANGE
• NO DILATATION OR EFFACEMENT
• WALKING LESSENS OR HAS NO EFFECT ON CONTRACTIONS
• FIRST STAGE OF LABOR–STARTS WITH BEGINNING OF
REGULAR CONTRACTIONS TO FULL DILATATION
• FIRST STAGE IS DIVIDED INTO THREE PHASES: LATENT, ACTIVE, AND TRANSITION
PHASES OF LABOR—FIRST STAGE
• LATENT---0--3 CENTIMETERS, CONTINUING EFFACEMENT
• ACTIVE---4--7 CENTIMETERS, COMPLETE EFFACEMENT
• TRANSITION 8--10 CENTIMTERS ENGAGEMENT
CONTRACTION CHARACTERISTICS• LATENT PHASE–MILD—10-30MIN. LASTING 20-40 SECONDS–MODERATE—5-7MIN. LASTING 30-40
SECONDS
• ACTIVE PHASE–MODERATE TO STRONG—2-3 MIN.
LASTING 40-60 SECONDS
• TRANSITION– STRONG—1-1/2-2 MIN. LASTING 60-90
SECONDS
PSYCHOLOGIC ADAPTIONSTO LABOR: LATENT PHASE
• FEELS ABLE TO COPE WITH DISCOMFORT• MAY BE RELIEVED THAT LABOR HAS
FINALLY STARTED• USUALLY ABLE TO TALK THROUGH
CONTRACTION• IS ABLE TO RECOGNIZE AND EXPRESS
FEELING OF ANXIETY
PSYCHOLOGIC ADAPTIONSTO LABOR: ACTIVE PHASE
• ANXIETY INCREASES• FEARS LOSS OF CONTROL• MAY HAVE DECREASED ABILITY TO COPE• LESS TALKATIVE
PSYCHOLOGIC ADAPTIONS TO LABOR: TRANSITION PHASE
• WITHDRAWS INTO HERSELF• DOUBTS ABILITY TO COPE• APPREHENSIVE AND IRRITABLE• TERRIFIED OF BEING ALONE• DOES NOT WANT ANYONE TO TALK TO
HER OR TOUCH HER• DIFFICULT TO CONCENTRATE ON TASK
SECOND STAGE OF LABOR
–BEGINS WITH COMPLETE CERVICAL DILATATION AND ENDS WITH THE BIRTH OF THE INFANT
LABOR REVIEW
• DESCRIBE THE FIVE CRITICAL FACTORS THAT INFLUENCE LABOR IN THE ASSESSMENT OF A MOTHER’S AND FETUS’ PROGRESS IN LABOR AND BIRTH, GIVING TWO EXAMPLES OF EACH
• RENAL -- >IN RENIN, PLASMA RENIN ACTIVITY, ANGIOTENSIN
• VOIDING CAN BE AFFECTED BY EDEMA,DISPLACEMENT
• GI—DECREASED MOTILITY, DELAYED STOMACH EMPTYING
• CARDIAC OUTPUT INCREASES
• WBC CAN INCREASE TO 25,000mm
• BP INCREASES
• ACID/BASE BALANCE—MAY SEE > Ph EARLY IN LABOR
INTRAPARTAL NURSING ASSESSMENT
• HISTORY–PERSONAL DATA–HX PREVIOUS ILLNESS–PROBLEMS IN PRENATAL PERIOD–PREGNANCY DATA–INFANT FEEDING METHOD CHOSEN–ANY PRENATAL EDUCATION ?–BIRTH PLAN
MATERNAL PSYCHOSOCIAL HISTORY
• POVERTY• NUTRITION• PRENATAL CARE• CULTURAL BELIEFS• ENVIRONMENT• USE OF DRUGS/ALCOHOL• DOMESTIC VIOLENCE
MATERNAL PSYCHOSOCIAL ISSUES
• EMOTIONAL STATUS• SOCIOCULTURAL BELIEFS• PREVIOUS CHILDBIRTH EXPERIENCE• SUPPORT• MENTAL AND PHYSICAL PREPARATION
INTRPARTAL ASSESSMENT STAGE ONE
• LABOR STATUS• FETAL STATUS• LAB VALUES• CULTURAL INFLUENCES• RESPONSE TO LABOR• CHILDBIRTH PREPARATION• ANXIETY• SUPPPORT
Figure 16–2 To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening. Before labor begins, the cervix is long (approximately 2.5 cm), the sides feel thick, and the cervical canal is closed, so an examining finger cannot be inserted. During labor, the cervix begins to dilate, and the size of the opening progresses from 1 cm to 10 cm in diameter.
FETAL ASSESSMENT
• FETAL POSITION– PALPATION—LEOPOLD’S MANEUVER– INSPECT SIZE AND SHAPE OF WOMAN’S
ABDOMEN– VAGINAL EXAM TO DETERMINE PRESENTING
PART – FETAL HEART RATE– ULTRASOUND
Figure 16–4 Top: The fetal head progressing through the pelvis. Bottom: The changes that the nurse will detect on palpation of the occiput through the cervix while doing a vaginal examination. Source: Myles, M. F. (1975). Textbook for midwives (p. 246). Edinburgh, Scotland: Churchill-Livingstone.
Figure 16–5d Fourth maneuver: Facing the woman’s feet, place both hands on the lower abdomen and move hands gently down the sides of the uterus toward the pubis. Note the cephalic prominence or brow.
GROUP EXERCISE
LIST THREE POTENTIAL PROBLEMS RELATED TO:PASSENGERPOSTIONPASSAGEWAYPHYSIOLOGICAL FORCES OF LABORPSYCHOSOCIAL ISSUES
• ELECTRONIC FETAL HEART RATE MONITOR--DOPPLER• BASELINE RATE—120-160BPM• WHAT CAUSES:–FETAL TACHYCARDIA–FETAL BRADYCARDIA
• ELECTRONIC MONITORING OF CONTRACTIONS
–TOCO—EXTERNATION ASSESSMENT OF CONTRACTIONS– IUPC—INTERNAL ASSESSMENT OF
CONTRACTIONS
EXTERNAL MONITORING
• EXTERNAL—ULTRASONIC TRANSDUCER (DOPPLER)–HIGH FREQUENCY SOUND WAVES
REFLECT MECHANICAL ACTION OF FETAL HEART
• DIFFICULT TO OBTAIN CONTINUOUS, ACCURATE RECORD AT TIMES
Figure 16–8 Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The toco provides information that can be used to monitor uterine contractions. The ultrasound device is placed over the area of the fetal back. This device transmits information about the fetal heart rate. Information from both the toco and the ultrasound device is transmitted to the electronic fetal monitor. The fetal heart rate is displayed in a digital display (as a blinking light), on the special monitor paper, and audibly (by adjusting a button on the monitor). The uterine contractions are displayed on the special monitor paper as well.
INTERNAL FHR MONITORING
–MEMBRANES MUST BE RUPTURED–CERVIX SUFFCIENTLY DILATED–PRESENTING PART LOW ENOUGH FOR
PLACEMENT
–SMALL ELECTRODE ATTACHED TO PRESENTING PART–MOST ACCURATE APPRAISAL OF FETAL
WELL-BEING IN LABOR
FHR MONITORING• VARIABILITY
–BEAT TO BEAT CHANGES IN FETAL HEART RATE–INDICATION OF AN INTACT CNS
•ABSENT•MODERATE•MARKED
Figure 16–10 Normal fetal heart rate pattern obtained by internal monitoring. Note normal FHR, 140 to 158 beats/min, presence of long- and short-term variability, and absence of deceleration with adequate contractions. Arrows on bottom of tracing indicate beginnings of uterine contractions.
Figure 16–12 Types and characteristics of early, late, and variable decelerations. Source: Hon, E. (1976). An introduction to fetal heart rate monitoring (2nd ed., p. 29). Los Angeles: University of Southern California School of Medicine.
FETAL ASSESSMENT• SCALP STIMULATION
• FETAL BLOOD SAMPLING (FBS)• NORMAL SCALP pH > 7.25, 7.20-7.25
BORDERLINE, <7.20 NONREASSURING–MEMBRANES MUST BE RUPTURED–CERVIX DILATED 2-3CM–PRESENTING PART -2 STATION OR LOWER
FIRST STAGE-- LATENT PHASE
–DILATATION, EFFACEMENT, STATION–MEMBRANE ASSESSMENT–COMFORT LEVEL–VS, FHR–UTERINE CONTRACTIONS EVERY 30-60
MIN.–TEACHING
LATENT PHASE
– ENCOURAGE AMBULATION– ENCOURAGE VOIDING Q2H–COMFORT MEASURES–NUTRITION OFFER FLUIDS–PAIN ASSESSMENT– EPIDURAL MONITORING– IDENTIFY AND OBSERVE SUPPORT
PERSON(S)
FIRST STAGE-- ACTIVE PHASE
– ENCOURAGE TO VOID Q1-2 HOURS–AUSCULTATE FHR Q15-30 MIN.–PALPATE CONTRACTIONS Q15 MIN.–VAGINAL EXAMS TO ACESS PROGRESS– EPIDURAL MONITORING, VS Q15-30 MIN.– START IV INFUSION IF UNABLE TO
TOLERATE FLUIDS–ACCESS COLOR AND ODOR OF AMNIOTIC
FLUID
FIRST STAGE-- TRANSITION
• PALPATE CONTRACTIONS Q15 MIN.• STERILE VAGINAL EXAMS TO ACCESS LABOR
PROGRESS• ASSESS FHR EVERY 15-30 MIN., DEPENDING
ON RISK FACTORS• ASSIST WITH BREATHING• KEEP WOMAN FROM PUSHING UNTIL 10 CM.• STAY WITH PATIENT!
INTRAPARTAL NURSING INTERVENTIONS SECOND AND THIRD STAGE OF LABOR
• SECOND AND THIRD STAGE OF LABOR• ENCOURAGMENT, ASSIST WITH
PUSHING,DO NOT LEAVE PATIENT– ASSIST WITH DELIVERY– DELIVERY OF PLACENTA– APGAR SCORE, IMMEDIATE CARE OF
NEWBORN– PITOCIN INFUSION
Figure 15–13 Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.
INTRAPARTAL NURSING CARE: THE THIRD STAGE
• DELIVERY OF THE PLACENTA–SCHULTZ MANUEVER–DUNCAN MANUEVER
PLACENTA ACCRETARETAINED PLACENTA
INTRAPARTAL NURSING CARE: THE FOURTH STAGE
–VS–FUNDUS–LOCHIA–PERINEUM/ABDOMINAL INCISION–BLADDER–COMFORT LEVEL–COMFORT MEASURES—WHAT ARE
THEY?
INTRAPARTAL NURSING CARE: THE FOURTH STAGE
–CONTINUE PITOCIN ADMINISTRATION---WHY?–PAIN MEDICATION–DIET–HEMODYNAMIC CHANGES
• CULTURAL CONSIDERATIONS
ADAPTION TO EXTRAUTERINE LIFE• IMMEDIATE CARE OF THE NEWBORN–RESPIRATORY ASSESSMENT
–CIRCULATORY ASSESSMENT
–THERMOREGULATION—HOW WOULD YOU ACHIEVE THIS?
IMMEDIATE CARE OF THE NEWBORN• APGAR SCORE• MAINTAIN RESPIRATIONS• PROVIDE AND MAINTAIN WARMTH• UMBILICAL CORD CARE• CORD BLOOD COLLECTION• HANDS OFF ASSESSMENT• NEWBORN IDENTIFICATION• FACILITATE ATTACHMENT
IMMEDIATE POSTPARTUM CARE OF MOTHER
• VS• HEMODYNAMIC CHANGES• FUNDUS, LOCHIA• VOIDING STATUS• EPISIOTOMY/LACERATION ASSESSMENT• PAIN
MATERNAL ANALGESIA & ANESTHESIA
• PAIN PERCEPTION AFFECTED BY:
–PREVIOUS EXPERIENCE–CULTURAL EXPECTATIONS, BELIEFS–FATIGUE, FEAR, ANXIETY–ENVIRONMENT–SUPPORT SYSTEM
Figure 18–3c Tip of needle in epidural space. Source: Bonica, J. J. (1972). Principles and practice of obstetric analgesia and anesthesia (p. 631). Philadelphia: Davis.
A
B C D
Figure 18–4 Levels of anesthesia for vaginal and cesarean births. Source: Reprinted with permission of Ross Laboratories, Columbus, OH. From Clinical Education Aid No. 17.
ANALGESIA AFTER DELIVERY
• EPIDURAL NARCOTIC ANALGESIA (DUROMORPH)– CONTRAINDICATIONS
– SIDE EFFECTS
– DOSAGE
BIRTH RELATED PROCEDURES• AMNIOTOMY
–ARTIFICIAL RUPTURE OF MEMBRANES (AROM
– SPONTANEOUS RUPTURE (SROM)
AMNIOTOMY
AFTER 3CM MAY SHORTEN LABOR (AROM) CAN BE A STIMULATION OF LABOR
FHR ASSESSED BEFORE AND AFTER AROM—WHY?
BIRTH RELATED PROCEDURES
• LABOR INDUCTION—STIMULATION OF UTERINE CONTRACTIONS
• INDICATED INDUCTION—WHAT CONDITIONS WOULD WARRANT AN INDICATED INDUCTION?
• ELECTIVE INDUCTION
BIRTH RELATED PROCEDURES
• ELECTIVE INDUCTIONS–INCREASE IN LAST 10 YEARS–CONTROVERSY, CONTROVERSY!!!!!!!–RISKS–EVIDENCE BASED PRACTICE—LATE
PRETERM NEWBORNS-- 34-37 WEEKS
BIRTH RELATED PROCEDURES• LABOR INDUCTION: STRIPPING OF
MEMBRANESADVANTAGES: LABOR USUALLY OCCURS WITHIN
24HOURSDISADVANTAGES:
CAN BE PAINFULUTERINE CONTRACTIONSBLOODY DISCHARGE
BIRTH RELATED PROCEDURES
LABOR INDUCTION/AUGMENTATIONRISKS:• HYPERSTIMULATION OF THE UTERUS• UTERINE RUPTURE• WATER INTOXICATION• NONREASSURING FETAL HEART RATE PATTERNS
BIRTH RELATED PROCEDURES
• CERVICAL RIPENING—PROSTAGLANDIN E2–RISKS•UTERINE HYPERSTIMULATION•NONREASSURING FETAL STAUS•HIGHER INCIDENCE OF POSTPARTUM
HEMORRHAGE•UTERINE RUPTURE
BIRTH RELATED PROCEDURES
• CERVICAL RIPENING– ADVANTAGES• SHORTER LABOR• LOWER REQUIREMENTS FOR OXYTOCIN IN
LABOR• VAGINAL BIRTH IS USUALLY ACHIEVED WITHIN
24 HOURS• INCIDENCE OF CESAREAN BIRTH IS REDUCED
• VERSION–EXTERNAL• EXTERNAL MANIPULATION
–INTERNAL •USED TO DELIVER SECOND TWIN
DURING VAGINAL BIRTH IF NOT DESCENDING OR IN DISTRESS--RARE
BIRTH RELATED PROCEDURES
• VACUUM EXTRACTION–SUCTION CUP PLACED ON FETAL
OCCIPUT–PUMP IS USED TO CREATE SUCTION–TRACTION IS APPLIED–FETAL HEAD SHOULD DESCEND WITH
EACH CONTRACTION
INDICATIONS FOR VACUUM EXTRACTION–PROLONGED SECOND STAGE OF LABOR
–NONREASSURING FETAL HEART RATE PATTERN–USED TO RELIEVE PUSHING EFFORT
(MATERNAL FATIGUE)–WHEN ANALGESIA INTERFERES WITH
ABILITY TO PUSH EFFECTIVELY–BORDERLINE CPD (CEPHALO-PELVIC
DISPROPORTION)
EPISIOTOMY
• SURGICAL INCISION OF PERINEUM TO ENLARGE OUTLET
• RESEARCH—EVIDENCE BASED PRACTICE• PREVENTATIVE MEASURES• TWO TYPES:– MEDIAN– MEDIOLATERAL
BIRTH RELATED PROCEDURES• INDICATIONS FOR CESAREAN BIRTH–CPD–PLACENTAL ABRUPTION–ACTIVE GENITAL HERPES–UMBILICAL CORD PROLAPSE– FAILURE TO PROGRESS IN LABOR–PROVEN NONREASSURING FHR PATTERN–COMPLETE PLACENTA PREVIA
BIRTH RELATED PROCEDURES• INDICATIONS FOR CESAREAN BIRTH
• BREECH PRESENTATION• PREVIOUS CESAREAN BIRTH•MAJOR CONGENITAL ANOMALIES• CERVICAL CERCLAGE• NON-REASSURING FHR PATTERNS
BIRTH RELATED PROCEDURES
• CESAREAN BIRTHSKIN INCISIONS
• TRANSVERSE (PFANNENSTIEL)• VERTICAL• UTERINE INCISIONS–TRANSVERSE–SELHEIM (LOWER UTERINE SEGMENT)–CLASSIC (UPPER SEGMENT OF
CORPUS)
BIRTH RELATED PROCEDURES
• PREPARATION FOR C-BIRTH
–MAJOR SURGERY
–SPINAL ANESTHESIA
– MANY TIMES PARENTS HAVE LITTLE TIME TO PREPARE PSYCHOLOGICALLY
BIRTH RELATED PROCEDURES• AMNIOINFUSION– INCREASES FLUID VOLUME IN UTERUS BY
INSTILLATION OF NORMAL SALINE INTO THE UTERUS–DECREASES PRESSURE ON THE CORD—
VARIABLE DECELERATIONS–PROMOTES INCREASED PERFUSION TO
FETUS–CAN DILUTE HEAVY MECONIUM FLUID–USED IN PRETERM LABOR WITH PPROM