Management of Discomfort

Chapter 19

Nonpharmacologic Strategies Cutaneous Stimulation Strategies

– Counterpressure *– Effleurage (light massage) *– Therapeutic touch & massage *– Walking *– Rocking *– Changing positions *– Application of heat or cold *– Transcutaneous electrical nerve stimulation– Acupressure– Water therapy (hydrotherapy)– Intradermal water block

Nonpharmacologic Strategies

Sensory Stimulation Strategies– Aromatherapy– Breathing techniques *– Music *– Imagery * – Use of focal points *

Nonpharmacologic Strategies

Cognitive Strategies– Childbirth education *– Hypnosis– Biofeedback

First Stage of Labor Systemic analgesia

– Opioid agonist analgesics– Opioid agonist-antagonist analgesics, co-

drugs Epidural (block) analgesia Combined spinal epidural (CSE)

analgesia Paracervical block (rarely used) Nitrous oxide

Second Stage of Labor Nerve block analgesia / anesthesia

– Local infiltration anesthesia– Pudendal block– Spinal (block) anesthesia– Epidural (block) analgesia– Combined spinal-epidural (CSE) analgesia

Nitrous oxide

Vaginal Birth

Local infiltration anesthesia Pudental block Epidural (block) analgesia / anesthesia Spinal (block) anesthesia Combined spinal – epidural (CSE)

analgesia / anesthesia Nitrous oxide

Cesarean Birth

Spinal (block) anesthesia Epidural (block) anesthesia General anesthesia

Nsg. Assessments (Fetal) Prior to med administration:

– FHR within normal range (no late decels or nonreassuring patterns).

– Average long term variability.– Present short term variability (with spiral

electrode).– Normal fetal movements.– Accels with fetal movement.– Term fetus. (EDC)

Nsg. Assessments (Maternal)

Prior to med administration:– Term pregnancy (EDC).– Evaluation of cervical dilation.– Evaluation of contraction pattern.– Evaluation of maternal comfort.– Med allergies.– Empty bladder.

Nsg. Assessments (Additional)

Prior to med administration:– A well established contraction pattern.– Fetal presenting part is engaged.– Cervix dilated.– Delivery should be anticipated but not

imminent.

Concerns: Regional Anesthesia Maternal hypotension, and subsequent

fetal distress. * Adverse maternal reactions. (can range

from palpitations to complete cardiovascular collapse).

Uteroplacental insufficiency.

Frequent monitoring of maternal vital signs & FHR are needed!

Fetal Assessment During Labor

Chapter 20

Assessment for Genetic Disorders Maternal age Ethnic background Family history Reproductive history Maternal disease Environmental hazards

Chapter 22

Strategies in Health Education and Counseling

Frame teaching to match the client’s perception

Fully inform clients of the purpose and expected effects

Be specific Use a combination of strategies Involve others Refer Monitor progress through follow-up

contacts Chapter 22

BIOPHYSICAL PROFILE (BPP)

A noninvasive assessment of the fetus and its environment by U/S, noting normal and abnormal biophysical responses to stimuli.

A normal BPP indicates that the CNS is functional and the fetus is not hypoxemic.

A scoring system, of 5 variables, with a total score up to 10.

Biophysical Profile Variables

Fetal breathing movements Gross body movement Fetal tone Amniotic fluid volume index Non-stress test

Chapter 22

BPP: VARIABLES & SCORESFETAL BREATHING MOVEMENTS: >1 episode in 30 min, each > 30

seconds. (normal score = 2) Episodes absent or no episode > 30 sec

in 30 min. (abnormal = 0)GROSS BODY MOVEMENTS: >3 discrete body or limb movements in

30 min. (normal = 2) < 3 episodes of body or limb movement

in 30 min. (abnormal =0)

FETAL TONE:> episodes of active extgension

with return to flexion of fetal limb(s) or trunk, opening & closing hand being considered normal tone. (normal =2)

Slow extension with return to flexion, movement of limb in full extension, or fetal movement absent. (abnormal = 0)

REACTIVE FETAL HEART RATE:> 2 episodes of acceleration (>15

bpm) in 20 min, each lasting > 15 sec. & associated with fetal movement. (normal = 2)

< 2 episodes of acdceleration or acceleration of < 15 bpm in 20 min. (abnormal = 0)

QUALITATIVE AMNIOTIC FLUID VOLUME:

> 1 pockets of fluid measuring >1 cm in 2 perpendicular planes. (normal =2)

Pockets absent or poscet < 1 cm in 2 perpendicular planes. (abnormal = 0)

Interpretation of BPP Scores:

Normal = 8-10 (if Amniotic fluid index is adequate)

Equivocal = 6 Abnormal = <4

Documentation of a Contraction Stress Test

Negative: No late decelerations with 3 adequate uterine contractions in a 10-minute window, normal baseline FHR and accelerations with fetal movement.

Positive: Late decelerations occur with more than half the uterine contractions.

Chapter 22

Documentation of a Contraction Stress Test (cont.)

Suspicious: Late decelerations occur with less than half the uterine contractions.

Unsatisfactory: Inadequate fetal heart rate recording or less than 3 uterine contractions in 10 minutes.

Chapter 22

Indications for the NST

Suspected post-maturity Maternal diabetes Maternal hypertension: chronic and

pregnancy-related disorders Suspected or documented IUGR History of previous stillbirth Isoimmunization

Chapter 22

Indications for the NST (cont.)

Older gravida Decreasing fetal movement Sever maternal anemia Multiple gestation High-risk antepartal conditions: PROM,

PTL, bleeding Chronic renal diseases

Chapter 22

Electronic Fetal Monitoring

External: ultrasound transducer Internal:

–spiral electrode

Ultrasound Transducer High-frequency sound waves reflect

mechanical action (fetal heart tone & valves) of the fetal heart.

Noninvasive. (Does NOT require rupture of membranes or cervical dilation)

Used in both antepartum and intrapartum period.

Short-term variability and beat-to-beat changes in the FHR cannot be assessed accurately by this method.

Spiral Electrode Applied to the fetal presenting part to

assess the FHR. Converts the fetal ECG as obtained

from the presenting part to the FHR via a cardiotachometer.

Used ONLY when membranes are ruptured & cervix is sufficiently dilated.

Short-term variability CAN be assessed using this method.

FHR Variability Increased Variability: marked variability

from a previous average variability.– Causes: early mild hypoxia; fetal

stimulation (uterine palpation, contractions, fetal activity; maternal activity; illicit drugs).

– Significance: unknown.– Nsg.Intervention: observe for any

nonreassuring patterns; if using external fetal monitoring consider an internal mode for a more accurate tracing.

FHR Variability Decreased Variability: marked

decrease in variability from a previous average variability.– Causes: hypoxia / acidosis; CNS

depressants; analgesics / narcotics; barbiturates; tranquilizers, anaractics; parasympatholytics; general anesthetics; prematurity (<24 wks); fetal sleep cycles; congenital abnormalities; fetal cardiac dysrhythmias.

FHR Variability Decreased Variability (continued):

– Significance: benign when associated with fetal sleep cycles; if drugs, variability usually increases as drugs are excreted; when associated with uncorrectable late decelerations indicates presence of fetal acidosis and can result in low APGARs.

– Nsg.Interventions: none, if fetal sleep cycle, or CNS depressants; consider fetal scalp stimulation or apply a spiral electrode; monitor fetal oxygen saturation; prepare for birth if indicated.

Other DEFINITIONS

Tachycardia: a baseline FHR >160 bpm for a duration of 10 minutes or longer.

Bradycardia: a baseline FHR <110 bpm for a duration of 10 minutes or longer.

FHR Changes

Accelerations Decelerations

– Early– Late– Variable– Prolonged

Baseline FHR

Definition: the average rate during a 10 minute period that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 bpm.

Range: 110-160 bpm.

Accelerations

Definition: A visually apparent abrupt increase in FHR above the baseline rate.

An increase of 15 bpm and lasting 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration.

Can be periodic or episodic.

Early Decelerations Definition: a transitory gradual

decrease and return to baseline FHR in response to fetal head compression.

Generally starts before the peak of the uterine contractions.

Returns to the baseline at the same time as the contraction returns to its baseline.

Considered benign. No interventions.

Late Decelerations Definition: a transitory gradual decrease in

and return to baseline of FHR associated with contractions.

Begins after the contraction has started, and the lowest part of the decel occurs after the peak of the contraction.

Usually does NOT return to baseline until after the contraction is over.

Indicates uteroplacental insufficiency. Interventions required!

Considered ominous sign when they’re uncorrectable, especially when associated with decreased variability and tachycardia.

Late Decelerations Interventions:

– Change maternal position (lateral)– Correct maternal hypotension (elevate legs)– Increase rate of maintenance IV– D/C oxytocin if infusing– Administer O2 at 8-10 L/min (face mask)– Fetal scalp or acoustic stimulation– Assist with fetal O2 saturation if ordered– Assist with birth if pattern cannot be

corrected.

Variable Decelerations Definition: an abrupt decrease in FHR that is

variable in duration, intensity,and timing related to onset of contractions; caused by umbilical cord compression.

Onset to the beginning of the nadir is <30 seconds; decrease in > 15 bpm, lating >15 seconds; variable times in contracting phase; often preceded by transitory acceleration.

Return to baseline is rapid and <2 min from onset; sometimes with transitory acceleration immediately before and after decel.

Described as: mild, moderate, or severe.

Variable Decelerations Interventions:

– Change maternal position (side to side). If severe:

– D/C oxytocin if infusing– Administer O2 at 8-10 L/min (face mask)– Assist with vag or speculum exam– If cord is prolapsed, examiner will elevate

fetal presenting part with cord between gloved fingers until c/s is accomplished

– Assist with amnioinfusion if ordered– Assist with fetal O2 saturation monitoring if

ordered– Assist with fetal O2 saturation if ordered

Prolonged Decelerations Definition: a visually apparent decrease in

FHR below the baseline 15 bpm or more and lasting more than 2 minutes but less than 10 minutes.

Benign causes: pelvic exam, application of spiral electrode, rapid fetal descent & sustained maternal valsalva maneuver.

Other causes (severe): progressive severe variable decels, sudden umbilical cord prolapse, hypotension, paracervical anesthesia, tetanic contraction & maternal hypoxia (may occur with seizure).

Nursing Care During Labor

Chapter 21

QUESTIONS TO ASK LABORING CLIENT:

UTERINE CONTRACTIONS Time of onset: What was the time of

the 1st ctx, & at what time did the ctx.become regular?

Frequency: How often do the ctx. occur?

Duration: How long do the ctx.last?

Intensity: What is the level of pain? Describe the nature & location of the pain?

Effect of Ambulation: do the ctx.become more or less frequent and intense with ambulation?

ADDITIONAL HISTORY: Bloody show: What was the frequency

& amt.of discharge? Vaginal bleeding: What was the

amount, color, and consistency?

Membranes: Is there leaking or have you experienced spontaneous rupture of membranes? What was the amont, color, consistency, & time of occurrence?

Fetal Activity: Has the fetus moved or kicked since labor began?

Nutrition, hydration, and sleep: When was the last time you ate, drank, or slept?

Social support available: Is someone with you?

General emotional well-being: Are you relaxed? Are you using breathing techniques? (can also be observed).

Transportation: Is transportation to the birth site available?

MONITORING DURING LABOR:

Purpose = to determine that maternal-fetal status is within normal limits during labor and that maternal status is within normal limits in the immediate postpartum period; to intervene when deviations from normal are noted.

Assess the following parameters during the 1st and 2nd stages of labor at regular intervals:

Vital signs: BP on admission & at least hourly during the active phase of labor (more frequently if elevated or epidural). T-P-R on admission & q4hr (more frequently if ROM or elevation).

Fetal well-being: auscultate & record FHR on admission or place on EFM for 20-30 min. Use continuous or intermittent monitoring depending on maternal-fetal risk.

Uterine activity: Assess & record frequency, duration, and intensity of uterine ctx q30-60 minutes by direct palpation or through interpretation of electronic fetal monitoring strips.

Labor progress: perform a vag.exam to assess cervical effacement & dilatation, fetal position & station, & status of membranes. (use Friedman’s curve).

I & O: ensure adequate hydration. Initiate IV fluid as needed or before administration of epidural. Encourage to empty bladder frequently.

HOW LABOR PROGRESS IS MEASURED:

Contraction pattern. Cervical consistency & effacement.

Cervical changes. Cervical dilatation. Station.

WAYS TO FACILITATE LABOR PROGRESS:

Work with ctx.rather than against them. Encourage relaxation between ctx. Assist in paced breathing techniques, focus, visual imagery, ambulation, change position regularly, good communication with nurse & support person.

PSYCHOSOCIAL ASSESSMENT IN LABOR:

Support system. Level of understanding of labor process &

procedures. Effectiveness of coping strategies to deal with

labor process & pain of level.

The psychosocial assessment provides the basis for education of the patient, anticipatory guidance, and provision of supportive care including both pharmacologic & nonpharmacologic measures

LABORATORY DATA: URINE: test for protein, ketones,

glucose, WBCs, nitrates (should all be negative).

HEMATOCRIT & HEMOGLOBIN: HCT <32%, and HGB <11g/L may indicate iron deficiency anemia or hemorrhage.

WBC COUNT: values of 4500 – 11,000 are normal; up to 25,000 can be normal for labor, birth, and early pp (d/t stress).

SEROLOGIC TESTS FOR SYPHILIS (VDRL): samples may be obtained on admission, depending on institutional policy. Results should be negative.

HEPATITIS B SURFACE ANTIGEN: repeat test if antepartum results are > 30 days old.

Rh FACTOR & ABO TYPING: necessary during the antepartum period, and pp when indicated.

PROMOTING A NORMAL CHILDBIRTH:

Maintain an awareness and appreciation of the individuality of each woman’s labor.

Be aware of cultural differences related to labor and birth.

Update your knowledge on intrapartum research topics (stay current).

Become reenergized by meeting and sharing with other professionals who work with the same challenges & issues. Join specialty organizations.

Know your professional standards of practice. These form your basis for safe practice.

Advocate for women’s needs on the basis of your knowledge of safe practice.

Be aware of your biases regarding labor and birth.

POSSIBLE NURSING DX:

FIRST-STAGE LABOR: Knowledge deficit: lack of information

related to expected physical changes, symptoms of labor, and options available to the childbearing woman.

Pain related to the process of labor or birth.

Anxiety related to childbirth, pelvic examinations, or obstetric interventions.

Fear related to parenting.

Fluid volume excess related to intake during labor.

Altered nutrition: less than body requirements related to decreased intake during labor.

SECOND-STAGE LABOR: Fear related to birth process, pain, and

unknown outcome. Fatigue related to physical exertion

during labor and lack of sleep. Pain related to fetal descent, crowning,

and perineal stretching.

THIRD- AND FOURTH-STAGE LABOR: Risk for infection related to uterine

placental site, episiotomy incision, and fatigue.

Urinary retention related to loss of sensation to void and rapid bladder filling.

Ineffective breastfeeding related to maternal knowledge deficit, anxiety, or fatigue.

“Friedman’s Curve” Emanuel Friedman began work in

1950s, and over 20 years defined the phases and length of the stages of labor for nulliparous and multiparous women.

His work showed that cervical dilatation & fetal descent follow a predictable pattern & appear as an S curve when plotted on a graph.

Analysis of labor progress is plotted on a graph (a partograph).

Can be used to plot cervical dilatation and fetal descent on the graph, and if labor begins to slow in comparison to the average rate of progress defined by Friedman, and this data can provide a basis for decision making about the progress of a woman’s labor.

Friedman’s work is the most universally accepted scientific treatment of labor & is nationally used in normal labor, and to diagnose dystocia (abnormal labor) when deviations are apparent.

LEOPOLD’S MANEUVERS: Purpose: to provide information about

fetal presentation, position, presenting part, lie, attitude, and descent.

Can aid in location of fetal heart tones, assessment of fetal size, and determination of single vs multiple gestation.

Used in late 2nd trimester or 3rd trimester, when fetal parts can be felt through abdominal wall.