Unit 2 OB Intrapartum

LABOR & DELIVERY

Rev. 2013

Signs of Impending Labor

1. Lightening

2. Bloody Show

3. Braxton Hicks Contractions

4. Energy Spurt

5. Weight Loss

True vs. False Labor

• Regular pattern

• Inc. in duration frequency & intensity

• Inc w/ ambulating

• Rarely follow a pattern

• Vary in duration, frequency and intensity

• Dec w/ ambulating

True vs. False Labor

• Start in back & radiate to abd.

• Dilate & efface cervix

• “show” usually is present

• Often noticed in abdomen

• No cervical changes

• “show” not present

2 Common signs of Active Labor

• 1. Strong, Regular Contractions

• 2. R.O.M.

Monitoring Fetal StatusUterine Contractions

• Involuntary

• Can be felt at uterine fundus

• Documented according to frequency, duration and intensity

Rupture of membranes

• B.O.W. Bag of Waters

• 1000cc or 1 qt. By 40th week

• Prior to delivery sac must break

• Amniotomy (SROM or AROM)

4 Stages of Labor

1. Dilation

* begins w/ onset of true labor

*ends w/ complete dilation of cervix

Primip ~ 10-12 hrs Multip 6-8 hrs

First Stage of Labor

• Has 3 distinct phases:

1. Latent excited

2. Active apprehensive

3. Transitional irritable & frustrated

2 distinct cervical changes

1. Dilation Cervical os begins to open Meas. In cm from 1-10 Complete dilation nec. to expel fetus Solely the result of contractions

2. EffacementRefers to thinning & shortening of

cervixNormally long & thickNow shortens or thinsMeas. in % (100%=complete)

2. Delivery or Expulsion

• Begins w/ complete dilation of cervix & ends w/ birth of newborn

Primip ~ 30 mins.- 2 hrs

Multip ~ 20 mins.- 1.5 hrs.

3. Placental

Begins w/ delivery of newborn & ends w/ delivery of placenta

(usually 5-20 mins.) for both primiparas and multiparas

4. Recovery/Stabilization

begins after delivery of placenta & ends w/ pt. being in stable condition

most crucial time for hemorrhage

(~ 2-4 hrs. After delivery)

Station,Lie,Position & Presentation

1. Station Means level of descent of fetal

presenting part in birth canal Measured in relation to the level of

ischial spines Vertex is most common presentation

At station 0, fetal head is engaged

Other stations are 1-3 cm above (-) or below (+) station 0

2. LieDenotes the position of the

fetal spinal cord (long part) to that of the woman

Normal lie is longitudinalTranverse lie cannot be

delivered

3. Position

refers to the relationship of the presenting fetal part to a quadrant of the maternal pelvis

Most favorable position is LOA

4. Presentation

• Refers to part of fetus that first enters birth canal

• 96% are cephalic or vertex presentation

• Other presentations are breech, face, shoulder

Breech Birth• Notice the foot

6

• It’ a boy

it's

• The body is almost out

Finally

Admission Assessment

Review Box 26-5 Pg. 828

CRITICAL THINKING QUESTION

•What are the 3 most important elements of your Admission Assessment?

Elimination/Activity/Exercise

• Keep bladder empty

• L side lying

• Breathing exercises

Relief of Discomfort

a. Epidural blockb. Saddle blockc. Caudal blockd. Pudental blocke. Paracervical or Cervical block

Fetal Monitoring

• Purpose:

- is to record fetal H.R. with

contractions & relaxation

- is to detect early warning

signs of fetal distress

Monitoring may be:

• External ( Indirect )

• Internal ( Direct )

Evaluation of Monitor Information

• Accelerations Transient inc. of the FHR of 15

BPM or more.Accelerations of 60 BPM or

more is considered a complication

Decelerations

Are slowing of the FHRAre a normal response of the

fetus to labor & should mirror the pattern of contraction.

Caused by head compression

Normal Variability

• Change in FHR from beat to beat

• Normal range is 2-10 beats/min

Decreased Variability

-Little or no fluctuation in FHR

May indicate fetal nervous system abnormality OR

Maternal use of CNS depressants

Signs of Fetal Distress

• Increase or decrease in baseline FHR

• Decrease in baseline variability

• Tachycardia

• bradycardia

Out to the neck

• Persistent late decelerations

• Severe variable decelerations

• Greenish-stained amniotic fluid

• Prolapsed cord

During the 2nd Stage of Labor:

Bearing down feelingRectum dilates, perineum

bulgesCrowning occursPerineal prep

Prepare for Delivery CoachingEpisiotomy done to prevent laceration

or tearingLacerations

Delivery of Newborn

1. Nose & mouth are suctioned

2. Check for nuchal cord

3. Note time of delivery

Response & Care of the Newborn to Birth

Establish & maintain airwayStimulate respirationsPosition to prevent aspirationProvide warmth Determine APGAR ScoreAssess cord for bleeding

Identification

Health Record

EES or Tetracycline to eyes

Vitamin K injection

Bonding

Third Stage of Labor

Extends from the time the newborn is delivered until the placenta & membranes are expelled

Can last up to 30 min., usually takes 5-20 min.

Delivery of Placenta

1. Shiney Schultze Dirty DuncanPlacental examinationOxytocin

Nursing Care during 3rd Stage

Massage fundus Cleanse perineum Remove legs from stirrups Change gown, apply peripad Provide warmth

Fourth Stage of Labor

• Involution begins

• 6 week process

Nursing Care during 4th Stage

1. Assess VS – q 15 min x 1-2 hours

2. Check fundus

3. Check perineum

4. Check lochia

5. Check for 1st void

6. Check for signs of hemorrhage

6. Patient Education Teach….

perineal careFundal massageFluid intake/voidingBreastsconstipation

after painsNursing/breast feeding

Complications of Labor & Delivery

A. Premature Rupture of Membranes

• Small leak in BOW causing a rupture of membranes

• May be difficult to diagnose

• Complications are: Premature labor,Intrauterine infection & malpresentations, prolapsed cord

Treatment

• Hospitalization

• Assessment of woman & fetus

• Determine fetal maturity

• Induce labor if fetus is mature

B. Premature Labor

• Labor that occurs before the 37th week

• Prematurity leading cause of infant mortality

• Tx is Bedrest, Tocolytic drugs

C. Precipitate L & D

Labor is brief < 3 hoursContractions unusually

severeMay be so rapid getting to

delivery room is impossible

Nursing Care

• Never prevent delivery

• Assist with birth

• Make sure neonate is breathing

D. Uterine Rupture

• One of the most serious complications – very rare

• Predisposing factors/causes

1. previous C/S or uterine scar

2. severe tonic contractions

3. Dystocia

4. Injudicious use of oxytocic drugs

5. CPD (Cephalopelvic Disproportion)

E. Dystocia

• Prolonged, difficult & painful labor

• Does not result in dilation or effacement

• Exhausts woman & predisposes to death

Causes of Dystocia

1. Uterine inertia

2. CPD

3. Abnormal fetal positions or presentations

Management for Abnormal Positions & Presentations….

1. Version (Leopold’s Maneuvers)

2. Forceps assisted delivery

3. Vacuum assisted delivery

4. C/S

F. Cord Problems

A. Prolapsed Cord umbilical precedes the baby Serious complication May cut off fetal circulation Requires emer. C/S

Nuchal Cord

• Cord wrapped around neck

• If discovered before labor,

C/S is done

*If not, forceps are used to speed delivery & cord cut immediately

Other Considerations of Labor & Delivery

The Induction Process• Drugs may be administered

parenterally, orally, or vaginally• Oxytocin most common• (PGE) Prostaglandin E

(Cervidil)• Amniotomy

Nursing Care during Induction

1. Note the time of amniotomy, color & amount of fluid

2. Monitor fetus for signs of distress

3. VS q 10-15 min. then q 30 min. fol. Rupture of membranes

Emergency DeliveryNever to be delayedRemain calm & deliver babyFollow aseptic techniqueDouble tie cord Keep baby warm, ensure

breathing

Cesarean Delivery

Post Op

Care

• Assess VS

• Observe lochia, incision & fundus

• I & O for 24-48 hrs

• Advance diet as tolerated

• Perineal care

• Early ambulation & breathing exercises

CRITICAL THINKING QUESTION

• A patient is in her third trimester and informs the nurse during her prenatal visit that she is experiencing constipation and stress incontinence. The patient asks the nurse how she can manage these problems. What information should the nurse provide for this patient?