Nursing Care of Mother and Infant During Labor and Birth Chapter 6 Nursing Care of Mother and Infant During Labor and Birth

Cultural Influences on Birth Practices Role of woman in labor and delivery Cultural preferences require flexibility Role of father/partner in labor and delivery May be driven by cultural practices Refer to Table 6-1, pages 117-119. Discuss the responsibilities of the nurse when interacting with families of different cultures. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Setting For Childbirth Hospitals Freestanding Birth Center Home Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Components of the Birth Process The 4 P’s Powers Passage Passenger Psyche Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Uterine Contractions The Powers Effect of contractions on the cervix Efface-thin Dilate -open Phase of contractions Increment- increase Peak-greatest Decrement- decreasing Frequency-beginning of 1 contraction to beginning of next Duration- time from the beginning until end of same one Intensity Mild Moderate Firm Maternal pushing A uterine contraction results from involuntary smooth muscle contractions. The contractions assist in the effacement (thinning) of the cervix. During labor, one of the nurse’s roles is to monitor uterine contractions. Define frequency and duration. What are the differences among mild, moderate, and firm contractions? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Cervical Effacement and Dilation Cervical effacement and dilation can be likened to sucking on a Lifesaver. As the candy becomes thinner, the center opening becomes wider. Describe the differences between cervical effacement and dilation for the primigravida and multigravida woman. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Contraction Cycle Nurses must understand the components of the contraction cycle. Review the increments and peak of the contraction pattern. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Tip Provide emotional support to the laboring woman so she is less anxious and fearful Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus What interventions can the nurse implement to reduce anxiety and fear during labor? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Passage Bony pelvis Soft tissues True False Directly involved in childbirth Inlet Midpelvis Outlet False Flares Upper portion of pelvis Soft tissues If previous delivery, will yield more readily to contractions and pushing efforts May not yield as readily in primiparas or older women Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Passenger—Fetal Skull The bones in the fetal head are separated by connective tissue. What is the importance of this tissue in relation to the birthing process? Compare and contrast the fontanels. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Fetal Skull Fontanelle: form where the sutures meet Anterior – diamond shape. Closes 12-18 months Posterior – triangular depression. Closes at 3 months Sutures and fontanelles allow fetal head to change shape as it passes through pelvis Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Passenger—Fetal Lie Fetal lie refers to the position of the fetus in relation to the maternal spine. Review the various fetal lie positions. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Passenger Lie- how fetus is oriented to mothers spine Attitude –head flexed forward and arms and legs flexed Presentation- fetal part the enters pelvis first Vertex- most favorable Frank breech –legs are flexed at hips ad extended toward shoulders Position- refers to how the reference point on fetal presenting part is oriented within the mother’s pelvis Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Passenger—Presentation Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Classifications of Fetal Presentations and Positions Review the terminology used in each of the fetal presentations. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Fetal Presentations and Positions First letter- R or L side of woman’s pelvis Second letter- fetal reference point Occiput- vertix presentations Mentum – chin- face presentation Sacrum- breech presentations Third letter- front or back of mother’s pelvis transverse denotes neither anterior or posterior Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Psyche Mental state can influence the course of labor The woman’s cultural and individual values influence how she will cope with childbirth Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Signs of Impending Labor Braxton Hicks contractions Increased vaginal discharge Bloody show Rupture of the membranes Energy spurt Weight loss Compare and contrast the clinical manifestations of Braxton Hicks contractions and true labor. Bloody show is a normal occurrence prior to the onset of labor. Describe the manifestations associated with bloody show. Rupture of membranes warrants evaluation of the pregnant woman at the health care facility. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Mechanisms of Labor Descent Engagement Flexion Internal rotation Station Engagement Flexion Internal rotation Extension External rotation Expulsion Mechanisms of labor refer to those physiological changes in positioning which take place during a normal vaginal delivery. Describe each of these positions. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Mechanisms of Labor Also referred to as “cardinal movements.” Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Birth Station Station refers to the position of the fetal head relative to the ischial spines. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

When to Go to the Hospital or Birth Center Contractions Ruptured membranes Bleeding other than bloody show Decreased fetal movement Any other concern What is the timeline for patient education concerning how and when to seek care? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Admission Data Collection Three major assessments performed promptly on admission Fetal condition- FHR Maternal condition- VS Impending birth Sitting on one buttocks Grunting Bearing down Bulging perineum Discuss Skill 6-1, Assisting with an Emergency Birth on page 130. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Admission Procedures Permits/consents Laboratory tests Intravenous infusion Perineal prep Determining fetal position and presentation Discuss the actions required for each task listed. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Comparison of False and True Labor False labor Contractions irregular Walking relieves contractions Bloody show usually not present No change in effacement/dilation of cervix True labor Contractions gradually develop a regular pattern Contractions become stronger and more effective with walking Discomfort in lower back/abdomen Bloody show often present Progressive effacement and dilation of cervix Refer to Table 6-2, page 131. What is the greatest difference between the types of labor? False labor does not result in cervical changes, while true labor causes changes in cervical dilation and effacement. At what point during the pregnancy should education be provided regarding false and true labor? Successful education should begin early in the pregnancy. This approach allows time for reinforcement throughout the pregnancy at each visit to the health care provider. Audience Response Question #1 Which is a characteristic of true labor? 1. Contractions are regular, and the intensity remains the same 2. Contractions are irregular, and the intensity remains the same 3. Contractions are regular and are intensified by walking 4. Contractions are regular and are not intensified by walking Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care Before Birth After admission to the labor unit, nursing care consists of Monitoring the fetus Monitoring the laboring woman Helping the woman cope with labor Fetal monitoring can be intermittent or continuous. Review factors which can determine the type of monitoring employed. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Monitoring the Fetus Fetal heart rate Intermittent auscultation Continuous electronic fetal monitoring Review Skill 6-2 on page 133, Box 6-2 on page 134, and Skill 6-3 on page 135. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Evaluating Fetal Heart Rate Patterns Baseline FHR – 2mins over 10min period – no contractions 110-160 BPM Fetal bradycardia <110 BPM Fetal tachycardia >160 BPM Baseline variability Fluctuation or constant changes in baseline heart rate with 10 mins Accelerations- temporary, abrupt rate increases of at least 15 beats/ min above the baseline FHR that last for less than 30 sec Late deceleration- begin after the beginning of contraction and do return to baseline. Suggests that placenta is not delivering enough oxygen to fetus Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Reassuring and Nonreassuring FHR and Uterine Activity Patterns Reassuring patterns Stable fetal heart rate (FHR) Moderate variability Accelerations Uterine contraction frequency greater than every 2 minutes; duration less than 90 seconds; relaxation interval of at least 60 seconds Nonreassuring patterns Tachycardia Bradycardia Decreased or absent variability; little fluctuation in rate Late decelerations Variable decelerations See Box 6-3 on page 137 for more details. A part of the nursing assessment is the evaluation of fetal heart patterns. Nonreassuring patterns require reporting to the health care provider. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Monitoring the Woman Vital signs Contractions Progress of labor Intake and output Response to labor Discuss the frequency of each of the items to be monitored. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Six Lamaze Institute Basic Practices for Maternity Care Labor should begin on its own Woman should have freedom of movement Woman should have a birth support person or doula Woman should be in non-supine positions Woman should not be separated from infant Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Helping the Woman Cope with Labor Labor support Teaching Providing encouragement Supporting/teaching the partner Teach how labor pains affect the woman’s behavior/attitude How to adapt responses to the woman’s behavior What to expect in his/her own emotional responses Effects of epidural analgesia Review the components of labor support with the class. What are the recommended positions of comfort for the laboring women? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Stages and Phases of Labor First stage-dilation and effacement (can last 4 to 6 hours) Second stage-expulsion of fetus (30 minutes to 2 hours) Third stage-expulsion of placenta (5 to 30 minutes) Fourth stage-recovery The labor of the primigravida will last longer than that of a multigravida. What behaviors are associated with each of the stages of labor? Audience Response Question #2 During which stage of labor does “crowning” occur? 1. First 2. Second 3. Third 4. Fourth Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Vaginal Birth After Cesarean Main Concern Uterine scar will rupture Can disrupt placental blood flow Lead to hemorrhage Woman may need more support than other laboring women Nurse provides empathy and support Discuss some of the psychological barriers that may arise for a woman with VBAC. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Responsibilities During Birth Assessing Apgar score Assessing infant for obvious abnormalities Examining the placenta Identifying mother and infant Promoting parent-infant bonding Preparing the delivery instruments and infant equipment Perineal scrub Administering medications Providing initial care to the infant Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Immediate Postpartum Period: Third and Fourth Stages of Labor Third stage-expulsion of placenta Schulze or Duncan’s Fourth stage—nursing care includes Identifying and preventing hemorrhage Evaluating and intervening for pain Observing bladder function and urine output Evaluating recovery from anesthesia Providing initial care to the newborn infant Promoting bonding and attachment between the infant and family After the birth of the baby, the nurse continues to assess the mother. Review both normal and abnormal findings. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care Immediately After Birth Care of the mother Observing for hemorrhage Vital signs Skin color Location and firmness of uterine fundus Lochia- pad check Pain Promoting comfort Keep warm and dry Ice to perineum to help reduce swelling and bruising Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care Immediately After Birth (cont.) Care of the infant Phase 1 From birth to 1 hour (usually in delivery room) Phase 2 From 1 to 3 hours (usually in transition nursery or postpartum unit) Phase 3 From 2 to 12 hours (usually in postpartum unit if rooming-in with the mother) If the newborn does not experience any difficulty with adaptation to extrauterine life, the infant will often remain with the mother in the delivery room. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Phase 1: Care of the Newborn Initial care includes Maintaining thermoregulation Maintaining cardiorespiratory function Observing for urination and/or passage of meconium Identifying the mother, father, and newborn Performing a brief assessment for major anomalies Encouraging bonding/breastfeeding Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Care of the Newborn Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Apgar Scoring Heart rate Respiratory effort Muscle tone Reflex response to suction or gentle stimulation on the soles of the feet Skin color Score – 8,9,10 healthy newborn The Apgar is performed twice. At what times is the scoring performed? A point-based system is used. Each of the parameters is given a score between 0 and 2 points. What are the implications of the score obtained? Audience Response Question #3 A neonate's Apgar score at 5 minutes is 9. In what category did this neonate most likely score a 1? 1. Heart rate 2. Respiratory effort 3. Muscle tone 4. Skin color 5. Reflex response Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Administering Medications to the Newborn Eye Care Vitamin K AquaMephyton Review Skill 6-6 on page 153 and Skill 6-7 on page 154. Audience Response Question #4 What medication is most often used for neonatal eye care? 1. Silver nitrate 1% 2. Triple dye 3. Silver nitrate 2% 4. Erythromycin ophthalmic ointment Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Observe for Major Anomalies Head trauma from delivery Symmetry and equality of extremities Are they of equal length? Do they move with same vigor on both sides? Assess digits of hands and feet Any evidence of webbing or abnormal number of digits What else should be assessed in regard to major anomalies? Which anomalies require immediate notification to the RN or health care provider? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Umbilical Cord Blood Banking This type of blood is capable of regenerating stem cells that are able to replace diseased cells Informed consent is essential Collect blood after cord has been clamped Blood must be transported within 48 hours of collection to blood banking facility Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.