Labor and Birth Processand

Nursing Management Chapter 13 & 14

Mary L. Dunlap MSN

Fall 2015

Labor Definition

• Coordinated sequence of involuntary uterine contractions

• Contractions 3 minutes apart or less lasting 60 seconds or longer

• Resulting in effacement and dilatation of the cervix and delivery of the fetus and placenta.

Possible Causes of Labor Maternal

• Uterine muscle stretching

• Pressure on the cervix

• Oxytocin

• Placental aging

• Estrogen/Progesterone ratio change

• Fetal cortisol concentration

• Prostaglandins

Possible Causes of Labor Fetal

• Placental aging

• Fetal Cortisol concentration

• Prostaglandin

4

Signs Preceding Labor

• Lightening

• Increase vaginal discharge

• Cervix softening

• Rupture of membranes

• Energy burst

• Braxton-Hicks contractions

• Weight loss

• Bloody show

False Labor

• Irregular contractions

• No regular pattern

• Discomfort in lower abdomen and groin

• Show is not present

• Does not cause cervical change

• Activity does not increase contractions

• Sedation will stop or decrease contractions

True Labor

• Regular contractions

• Contractions Progresses to a pattern

• Discomfort begins in back and radiates to the abdomen

• Activity increases contraction frequency

• Sedation does not diminish contraction pattern

• Causes cervical changes

• Show usually present

Factors That Affect Labor

The Five P’s:

• Passageway (birth canal)

• Passenger (fetus and placenta)

• Powers (contractions)

• Position of the mother

• Psychologic response

Passageway

• Pelvic structure and shape• Soft tissues cervix Pelvic floor Vagina

Passenger• Size of the fetal head• Presenting part • Fetal lie• Fetal attitude• Fetal position

Passenger: Fetal Skull

• Largest and least compressible structure

• Sutures: allow for overlapping and changes in shape (molding); help identify position of fetal head

• Fontanels: intersections of sutures; help in identifying position of fetal head and in molding

Fetal Skull

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Passenger: Presenting Part

• Cephalic • Breech

FrankFull or completeFootling or incomplete

• Shoulder

Breech Presentations

Fetal Lie

• Fetal lie is the relationship of the spine of the fetus to the spine of the mother

• Longitudinal

• Transverse

Fetal Attitude

• Fetal attitude is flexion or extension of the joints and the relationship of fetal parts to one another

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Passenger: Fetal Position

• Fetal position- relationship of the presenting part of the fetus to a designated point of the maternal pelvic structure

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Powers

Contractions primary force

• Frequency

• Duration

• Intensity

Pushing secondary force

Maternal Position

• Affects woman’s anatomic and physiologic adaptations to labor

• Frequent changes in positionRelieve fatigueIncrease comfortImprove circulationFacilitates decent and rotation

Psychological ResponseFactors Influencing a Positive Birth Experience

•Clear information on procedures

•Support, not being alone

•Sense of mastery, self-confidence

•Trust in staff caring for her

•Positive reaction to the pregnancy

•Personal control over breathing

•Preparation for the childbirth experience

Factors That Affect Labor

5 Additional P’s

•Philosophy

•Partner

•Patience

•Pain management

Cardinal movements of Labor

• Engagement• Descent• Flexion• Internal rotation • Extension• External rotation (restitution)• Expulsion (birth)

Four Stages of Labor

First Stage starts with Onset of labor to complete dilation

• Latent phase Dilatation 0 to 3 cm

Effacement 0 to 40%• Active phase Dilatation 4 to 7 cm

Effacement 40 to 80%• Transition Dilatation 8–10 cm

Effacement 100%

Stages of Labor

• Second stage–complete dilation to birth

• Third stage–birth to placental separation and expulsion

• Fourth stage–four hours following delivery of the placenta

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Initial Maternal Assessment

• Presenting complaint• EDC• Gravida/Para• Contraction Pattern• Membrane status• Presence of fetal movement• Complications

Fetal Assessment

• FHR provides information about the fetal oxygen status.

• Locations for auscultating• Doppler Nursing Procedure 12.1 pg. 355

• Continuous FHR via ultrasound transducer

• Fetal movement

Doppler

Doppler

Continuous Fetal Monitoring

Contraction Assessment

• Frequency

• Duration

• Strength/Intensity

• Resting tone

Contraction Phases

39

Pelvic Exam

• Effacement

• Dilation

• Presenting part

• Station

• Status of membranes

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General Systems Assessment

• Vital signs

• General physical assessment

• Leopold’s maneuvers Procedure 14.1 pg. 424

• DTR and clonus

• Review prenatal record for lab results and history

Leopold’s Maneuver Video12310

• Leopold's Maneuver

Physiologic Adaptation to Labor

Maternal Adaptation• Cardiovascular changes• Respiratory changes• Musculoskeletal changes• Gastrointestinal changes

Physiologic Adaptation to Labor

Fetal adaptation to labor

• Fetal heart rate changes due to contractions

• Fetal circulation & respiratory changes preparing for birth

• Fetal heart rate baseline and variability

• Fetal heart rate response to contractions

Nurses Role

• During labor and delivery fetal assessment includes determining fetal well-being and interpreting signs and symptoms of possible compromise

• Nurse needs to be knowledgeable of the different FHR categories and the appropriate interventions that may be required

Monitoring Techniques

Electronic fetal monitoring• External monitoring

FHR—ultrasound transducerUCs—Toco transducer

• Internal monitoring (invasive)Spiral electrode (FSE)Intrauterine pressure catheter (IUPC)

Amnio Hook

Fetal Scalp Electrode

Placement of FSE

IUPC

Internal Fetal Monitoring

FHR Categories

• Category I normal

• Category II indeterminate

• Category III Predictive of abnormal fetus

acid base status

Tab. 14.1 pg.429

Determining FHR Patterns

Fetal assessment

• Baseline FHR

• Variability

• Accelerations

• Periodic changes (decelerations)

Early (head compression)

Late (placental insufficiency)

Variable (cord compression)

Baseline Fetal Heart Rate

• Baseline Rate is the average FHR that occurs during a 10-minute segment excluding periodic or episodic rate changes

• Normal 110-160

• Bradycardia <110

• Tachycardia >160

Fetal Heart Rate Variability

• Irregular Fluctuations in FHR baseline measured as amplitude of the peak to trough in bpm

• Absent fluctuation undetectable

• Minimal <5 bpm

• Moderate (normal) 6-25 bpm

• Marked >25bpm

Fetal Heart Rate Patterns

Changes in fetal heart rate• Periodic occur with Contractions• Episodic (non-periodic) not associated

with contractions• Accelerations• Decelerations

Accelerations

• Positive sign of fetal wellbeing

• Abrupt increase in FHR above the base line lasting <30 sec from onset to peak

• Term 15 bpm above baseline & duration >15 sec. but <2min

• Prior to 32 weeks 10 by 10

• Prolonged 2 min. to <10min

Decelerations

• Early decelerations

• Late decelerations

• Variable decelerations

• Prolonged decelerations

Early Decelerations

• Gradual decrease in FHR, nadir coincides with the peak of the contraction

• Mirror image of the contraction

• Head compression/vagal response

• No treatment required/benign pattern

Late Decelerations

• Gradual decrease in FHR with the nadir of the deceleration occurring after the peak of the contraction. The FHR does not return to baseline until the contraction has ended

• Caused by uteroplacental insufficiency

• Fetus is in distress

• Interventions Box 14.1 pg.432

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Variable Decelerations

• Abrupt decrease in FHR below the baseline. The decrease is at least 15 bpm, lasting between 15 sec and under 2 minutes. They can vary with contractions.

• Shaped like a “V” or a “W”

• Associated with cord compression

Prolonged Deceleration

• Abrupt decrease in FHR of at least 15 bpm lasting longer than 2 minutes, but less than 10 minutes.

• FHR usually drops to less than 90 bpm

Decelerations

Fetal Heart Rate

• V Variable

• E Early

• A Acceleration

• L Late

• C Cord

• H Head Compression

• O Oxygenated fetus

• P Placental problems

Fetal Assessment Methods

• Umbilical Cord Blood Analysis

• Fetal Scalp Stimulation

Pain Management

• Nonpharmacologic

• Pharmacologic

Nonpharmacologic Management

• Simple, safe, and inexpensive

• Provide sense of control over childbirth

• Natural child birth requires practice for best results

• Try variety of methods and seek alternatives, including pharmacologic methods if needed

Nonpharmacologic Management

• Imagery and visualization• Position Changes Table 14.2 pg.437

• Music

• Touch and massage

• Breathing techniques

• Effleurage and counter pressure

• Water therapy (hydrotherapy)

Pharmacologic Management

• Systemic Analgesia

• Regional Analgesia/Anesthesia

Systemic Analgesia• Use of one or more drugs administered

orally, IM, or IV. These meds are distributed via the circulatory system.

• Pain relief can occur within a few min. and last up to several hrs.

• Side effect can be respiratory depression in the mother as well as the newborn after birth

Systemic Analgesia• Opioids

• Ataractics/Antiemetics

• Benzodiazepines

• Drug Guide 14.1 pg. 441

Regional Analgesia/Anesthesia

• Pudendal never block

• Epidural (Vaginal Del or C/S)

• Spinal (C/S)

• General (C/S)

Epidural Analgesia

•Combination of local anesthetic (lidocaine) & an opioid (morphine or fentanyl)

•Injected into the epidural space•Medication can be balanced to provide pain relive and the ability to ambulate

Epidural Analgesia

General Anesthesia

• Reserved for emergency cesarean births when there is not enough time to do a spinal or epidural for anesthesia

• Combination of IV injection and inhalation agents

Epidurals/Spinals/General Anesthesia

• Anesthesia interview

• Consent form

• Labs (platelets less than 100,000 can place an epidural/spinal)

Nursing Responsibilities During 1st Stage of Labor

• Vital signs

• Hydration and nutrition

• Elimination

• Assessment of contractions and FHR

• Labor Support

• Comfort measures/Pain management

• Education

Second Stage of Labor

• Assessment of contractions and FHR

• Fetal descent

• Psychological considerations

• Maternal positioning

• Coaching maternal breathing and pushing efforts

Preparation for Delivery

• Prepare instrument table

• Adequate lighting

• Oxygen and suction equipment

• Radiant warmer, blankets,

• identification for newborn

• Pitocin

Delivery Table

Preparation for Delivery

• Positioning of mother for birth

• Gown, gloves, and protective equipment for personnel

• Cleansing of the perineum

• Deliver the newborn

Second Stage of Labor

• Perineal Lacerations (Depth) * 1st degree * 2nd degree * 3rd degree * 4th degree• Episiotomy * midline * mediolateral

Third Stage of Labor

Delivery of the placenta• Assess for perineal trauma• Repair of episiotomy/Perineal

lacerations• Newborn care• Emotional support /Foster bonding

Episiotomy

Episiotomy Repair

Third Stage of Labor

Placental separation and expulsion

• Firmly contracting fundus

• Change in uterus

• Sudden gush of dark blood from introitus

• Apparent lengthening of umbilical cord

• Vaginal fullness

Fetal Side

Maternal Side

Third Stage of Labor

Newborn care• Time of birth noted• Drying, stimulation, suctioning of the

newborn• Respiratory effort, heart rate, color, tone

noted• One- and five-minute Apgar scores• Cord blood obtained• Identification

Apgar ScoreAssessment 0 Point 1 Point 2 Point

Heart Rate Absent < 100 bpm > 100 bpm

Respiratory effort Apneic Slow, irregular, shallow

Regular 30-60 breaths/min

Strong, good cry

Muscle Tone Limp, Flaccid Some flexion, limited resistance

to extension

Tight flexion, good resistance to extension with quick response to

flexed position

Reflex irritability No Response Grimace or frown when irritated

Sneeze, cough, or vigorous cry

Skin color Cyanotic or Pale Appropriate body color; blue extremities

Completely pink

Apgar Score

• http://www.youtube.com/watch?v=hdNVhDuD4wU

Fourth Stage of Labor

Maternal Assessment• Uterus• Lochia• Perineum• Bladder• Vital signs• Pain• Newborn-family attachment• Breastfeeding initiated