Chapter 66 Normal Labor, Delivery, and Postpartum Care

EMTALA What is it?

Labor and Delivery Six major factors Psyche- the mother’s psychological response to labor Powers- uterine contractions>frequency, duration>90.>Intensity> effacement>Dilation Passenger-fetus and placenta Presentation-the first part to enter the pelvic- cephalic, breech and shoulder>station negative above the ischial spines-1, -2 Zero-at the ischial spine=engaged(0) Positive 1-3

Powers Position-relationship of presenting part to the maternal pelvic inlet Passage-birth canal, pelvis, cervix pelvic floor and vagina Cephalopelvic disproportion

Labor meds Oxytocin Misoprostol Penicillin G Methylergonovine Terbutaline sulfate Betamethasone Methotrexate Indomethacin

Labor False True Braxton hicks Stop by action No cervical changes No bloody show Not engaged contractions

Fetal heart rate 110-160 Variability best indicator of well-being Moderate +6to 25/min For internal monitor ruptured membrane – can increase infection – All pelvic checks _sterile technique

FHR Monitoring VEAL=Name CHOP =cause MINE= management

The Four Stages of Labor Series of events during which a woman’s uterus contracts and expels a fetus and completes the birthing process Stage I: Dilation-latent,active, transitional ROM, - nitrazine paper ph 6.5-7.5-blue-pain management Stage II: Expulsion-push>prevent hyperventiliation Stage III: Placental-VS;bleeding; fundus;baby care Stage IV: Recovery-Hemorrhage priority concern/bonding

NCLEX Alert!!!!!!!!!!!!!! Pharmacologic pain Procedures Warnings

Intrapartum and Postpartum Time period during which labor and delivery take place Postpartum Follows the intrapartum period Lasts until the end of the sixth week after the birth

Choices in Labor and Birth Birth attendant Birth setting Birth plan Nurse’s role Inform the policies of the birth setting and birth attendant, and of the need for flexibility if complications develop.

Terminology Relating to Pregnancy and Birth Nulligravida Nullipara Primigravida Multigravida Primipara Multipara

The Process of Labor Lie Position of the fetal spinal cord to that of the woman Normal lie, transverse lie Presentation Cephalic presentation: Vertex presentation, face presentation, brow presentation Breech presentation Shoulder presentation

The Process of Labor (cont’d) Station Descent level of the fetal presenting part into the birth canal Engagement Fetal head has moved downward in the birth canal; it can no longer be pushed up and out of the pelvis. Position Relationship between the presenting part of the fetus to a designated point on one of four quadrants of the woman’s pelvis

Variations of Breech Position Complete breech: Both legs drawn up, bent at both the hip and the knee Frank breech: Hips bent, but the knees are extended Kneeling breech: Either one or both legs are extended at the hip, flexed at the knee Footling breech: Either one or both legs are extended both at the hip and knee In all types of breech presentation positions, the sacrum is the assigned point.

Question Is the following statement true or false? If the fetus is in a footling breech position, delivery may be difficult or dangerous.

Answer True In a footling breech position, there is a chance the umbilical cord could prolapse because there is so much empty space within the uterus. This could cut off the blood and oxygen supply to the fetus before it is born.

Signs of Approaching Labor The 4 P’s of labor Passage, passenger, powers, and psyche Lightening Settling of the fetus into the pelvis. 2 to 3 weeks before labor begins in primigravidas; may not occur until labor begins in multigravidas Braxton-Hicks contractions Show

True Versus False Labor True labor Contractions: Timing Irregularly spaced Regular, rhythmic Duration, frequency, and intensity Variable Increases and becomes closer and stronger over time Effect of position or activity change Contractions lessen Becomes stronger with ambulation or activity Location where felt Primarily in low abdomen Starts in back, radiate to abdomen Cervical change and presence of “show” None Progressive effacement and dilation, show is usually present

Uterine Contractions Each labor contraction has three phases. Increment: Contraction builds from the resting phase to full strength. Acme: Contraction is at full intensity. Decrement: Uterine contraction eases, until the resting state is achieved. Relaxation The time between contractions

Question Is the following statement true or false? The nurse should report immediately if the client’s contractions come more often than every 2 minutes or if each contraction lasts 90 seconds or longer, or if any yellow, green, or cloudy amniotic fluid is present.

Answer True This is because there is not enough relaxation time for the fetus to be well oxygenated. This event is rare during normal labor but must be carefully watched for when oxytocin is used for labor augmentation or induction. Normal amniotic fluid is clear and colorless, and has a slightly salty odor. Yellow or green fluid may indicate the fetus has passed meconium (stool) while still in utero. White or cloudy fluid may indicate the presence of pus in response to an infection.

Nursing Care During Stage I of Labor Focuses on frequent monitoring of the woman’s vital signs, contractions, and cervical change, as well as the fetus’ well-being cervix dilates Admission Observation and data gathering Emotional and physical support Relief of discomfort

Nursing Care During Stage 1 of Labor (cont’d) Assessing fetal well-being Intermittent auscultation Electronic fetal monitoring Evaluation of fetal monitor information Accelerations Decelerations Decreased variability

Question Is the following statement true or false? Late decelerations in fetal heart rate occur anytime during or after contractions.

Answer False Variable decelerations in fetal heart rate occur anytime during or after contractions. They usually indicate umbilical cord compression and can usually be altered by changing the woman’s position or by giving her oxygen. Late decelerations begin late in the contraction, and the fetal heart rate recovery occurs after the contraction is over. Decelerations are related to placental insufficiency and indicate fetal distress. The fetal heart rate should not fall below 100 bpm.

Nursing Care During Stage II of Labor Maternal care An LPN/LVN or RN will assist in delivery. Coaching the client Encourage the woman to push only with contractions and to rest between them. Episiotomy Incision in the perineum Neonatal care

Nursing Care During Stage III of Labor Stage III is short; there may be possibility of hemorrhage. The nurse records: Time of placenta delivery, spontaneous delivery or manual removal, side of the placenta presented Nurse may be instructed to administer oxytocics or to massage the fundus gently to minimize blood loss. Birth attendant Examines and cleans the cervix and vagina, episiotomy or lacerations, the vulva and perineum and remove stirrups

Nursing Care During Stage IV of Labor Observations and data gathering Vital signs, fundus of the uterus and the perineum, lochia, mother’s first voiding after delivery Maternal and newborn feeding Encourage mother to drink fluids and to put the newborn to her breast Transfer from the recovery room Record delivery and other procedures. Postpartum care: Client teaching

Necessary Documentation for Delivery Complete information about the type of delivery and procedures used; who was present Sex and condition of the baby (include Apgar score) Time of birth and time at which the placenta was expelled and presentation Condition of the fundus Any medication administered If an episiotomy was done, and its type Condition and vital signs of the mother and measured maternal blood loss

Changes in Maternal Anatomy Involution: Reproductive organs return to their nonpregnant state. Uterus: Postpartum period: The uterus should be positioned midline and feel firm to the touch. Abnormal: Deviation to the side, soft or boggy Lochia: Normally continues for 3 to 4 weeks—Lochia rubra, Lochia serosa, Lochia alba Abnormal: Large clots, foul odor

Changes in Maternal Anatomy Cervix constricts and firms during the postpartum period. The vagina regains muscle tone. Episiotomy and perineum should appear clean, with very slight edema. Abnormal: Inflammation, redness, and discharge from the episiotomy or lacerations, hematomas, ecchymosis, and edema Abdominal muscle tone is regained by 6 weeks after delivery. Breasts: Prepare for the newborn’s nourishment; may engorge

Changes in Maternal Anatomy Bladder: New mothers may have stress incontinence or difficulty voiding. Abnormal: Voiding in small amounts, residual urine, dysuria, bladder infection, urinary retention Gastrointestinal system: Mother may be constipated for 1 to 2 weeks following delivery pregnancy and may have problems with hemorrhoids after the birth. Extremities Abnormal: Redness, pain, and swelling along the path of a vein—superficial thrombophlebitis

Question Is the following statement true or false? It is important to massage a contracted fundus.

Answer False Never massage a contracted fundus because massage of an already contracted uterus may cause it to invert, which can present an emergency situation. Observe the amount, color, and odor of the lochia.

Client Teaching Begins at the time of admission Breast care, nursing and engorgement Perineal care, care of the stitches and fundus observation Involution Activity, rest, and diet Fluid intake, voiding Bathing, ambulation

End of Presentation