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

• Slide 1
• Slide 2
• Slide 3
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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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• Slide 157

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

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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

• Slide 1
• Slide 2
• Slide 3
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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

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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

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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

• Slide 1
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• Slide 153
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• Slide 156
• Slide 157

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
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• Slide 157

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

• Slide 1
• Slide 2
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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

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
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• Slide 151
• Slide 152
• Slide 153
• Slide 154
• Slide 155
• 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

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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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• Slide 150
• Slide 151
• Slide 152
• Slide 153
• Slide 154
• Slide 155
• Slide 156
• Slide 157

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

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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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• Slide 154
• Slide 155
• Slide 156
• Slide 157

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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• Slide 154
• Slide 155
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• Slide 157

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 156
• Slide 157

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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• Slide 156
• Slide 157

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 155
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• Slide 157

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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• Slide 156
• Slide 157

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 157

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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