Unit 2 OB Intrapartum LABOR & DELIVERY Rev. 2013

Signs of Impending Labor 1.Lightening 2.Bloody Show 3.Braxton Hicks Contractions 4.Energy Spurt 5.Weight Loss

True vs. False Labor Regular pattern Inc. in duration frequency & intensity Inc w/ ambulating Rarely follow a pattern Vary in duration, frequency and intensity Dec w/ ambulating

True vs. False Labor Start in back & radiate to abd. Dilate & efface cervix “show” usually is present Often noticed in abdomen No cervical changes “show” not present

2 Common signs of Active Labor 1. Strong, Regular Contractions 2. R.O.M.

Monitoring Fetal Status Uterine Contractions Involuntary Can be felt at uterine fundus Documented according to frequency, duration and intensity

Rupture of membranes B.O.W.  Bag of Waters 1000cc or 1 qt. By 40 th week Prior to delivery sac must break Amniotomy (SROM or AROM)

4 Stages of Labor 1.Dilation * begins w/ onset of true labor *ends w/ complete dilation of cervix Primip ~ hrs Multip 6-8 hrs

First Stage of Labor Has 3 distinct phases: 1. Latent  excited 2. Active  apprehensive 3. Transitional  irritable & frustrated

2 distinct cervical changes 1.Dilation  Cervical os begins to open  Meas. In cm from 1-10  Complete dilation nec. to expel fetus  Solely the result of contractions

2. Effacement  Refers to thinning & shortening of cervix  Normally long & thick  Now shortens or thins  Meas. in % (100%=complete)

2. Delivery or Expulsion Begins w/ complete dilation of cervix & ends w/ birth of newborn Primip ~ 30 mins.- 2 hrs Multip ~ 20 mins hrs.

3. Placental Begins w/ delivery of newborn & ends w/ delivery of placenta (usually 5-20 mins.) for both primiparas and multiparas

4. Recovery/Stabilization begins after delivery of placenta & ends w/ pt. being in stable condition most crucial time for hemorrhage (~ 2-4 hrs. After delivery)

Station,Lie,Position & Presentation 1.Station  Means level of descent of fetal presenting part in birth canal  Measured in relation to the level of ischial spines  Vertex is most common presentation

 At station 0, fetal head is engaged  Other stations are 1-3 cm above (-) or below (+) station 0

2. Lie  Denotes the position of the fetal spinal cord (long part) to that of the woman  Normal lie is longitudinal  Tranverse lie cannot be delivered

3. Position  refers to the relationship of the presenting fetal part to a quadrant of the maternal pelvis  Most favorable position is LOA

4. Presentation Refers to part of fetus that first enters birth canal 96% are cephalic or vertex presentation Other presentations are breech, face, shoulder

Breech Birth Notice the foot 6

It’ a boy i t's

The body is almost out F inally

Admission Assessment Review Box 26-5 Pg. 828

CRITICAL THINKING QUESTION What are the 3 most important elements of your Admission Assessment?

Elimination/Activity/Exercise Keep bladder empty L side lying Breathing exercises

Relief of Discomfort a.Epidural block b.Saddle block c.Caudal block d.Pudental block e.Paracervical or Cervical block

Fetal Monitoring Purpose: - is to record fetal H.R. with contractions & relaxation - is to detect early warning signs of fetal distress

Monitoring may be: External ( Indirect ) Internal ( Direct )

Evaluation of Monitor Information Accelerations  Transient inc. of the FHR of 15 BPM or more.  Accelerations of 60 BPM or more is considered a complication

Decelerations  Are slowing of the FHR  Are a normal response of the fetus to labor & should mirror the pattern of contraction.  Caused by head compression

Normal Variability Change in FHR from beat to beat Normal range is 2-10 beats/min

Decreased Variability -Little or no fluctuation in FHR May indicate fetal nervous system abnormality OR Maternal use of CNS depressants

Signs of Fetal Distress Increase or decrease in baseline FHR Decrease in baseline variability Tachycardia bradycardia

Out to the neck

Persistent late decelerations Severe variable decelerations Greenish-stained amniotic fluid Prolapsed cord

During the 2nd Stage of Labor:  Bearing down feeling  Rectum dilates, perineum bulges  Crowning occurs  Perineal prep

 Prepare for Delivery  Coaching  Episiotomy done to prevent laceration or tearing  Lacerations

Delivery of Newborn 1. Nose & mouth are suctioned 2. Check for nuchal cord 3. Note time of delivery

Response & Care of the Newborn to Birth Establish & maintain airway Stimulate respirations Position to prevent aspiration Provide warmth Determine APGAR Score Assess cord for bleeding

Identification Health Record EES or Tetracycline to eyes Vitamin K injection Bonding

Third Stage of Labor  Extends from the time the newborn is delivered until the placenta & membranes are expelled  Can last up to 30 min., usually takes 5-20 min.

Delivery of Placenta  1. Shiney Schultze  Dirty Duncan  Placental examination  Oxytocin

Nursing Care during 3 rd Stage  Massage fundus  Cleanse perineum  Remove legs from stirrups  Change gown, apply peripad  Provide warmth

Fourth Stage of Labor Involution begins 6 week process

Nursing Care during 4 th Stage 1.Assess VS – q 15 min x 1-2 hours 2.Check fundus 3.Check perineum

4. Check lochia 5. Check for 1 st void 6. Check for signs of hemorrhage

6. Patient Education  Teach….  perineal care  Fundal massage  Fluid intake/voiding  Breasts  constipation

 after pains  Nursing/breast feeding

Complications of Labor & Delivery

A. Premature Rupture of Membranes Small leak in BOW causing a rupture of membranes May be difficult to diagnose Complications are: Premature labor,Intrauterine infection & malpresentations, prolapsed cord

Treatment Hospitalization Assessment of woman & fetus Determine fetal maturity Induce labor if fetus is mature

B. Premature Labor Labor that occurs before the 37 th week Prematurity leading cause of infant mortality Tx is Bedrest, Tocolytic drugs

C. Precipitate L & D  Labor is brief < 3 hours  Contractions unusually severe  May be so rapid getting to delivery room is impossible

Nursing Care Never prevent delivery Assist with birth Make sure neonate is breathing

D. Uterine Rupture One of the most serious complications – very rare Predisposing factors/causes 1. previous C/S or uterine scar 2. severe tonic contractions

3. Dystocia 4. Injudicious use of oxytocic drugs 5. CPD (Cephalopelvic Disproportion)

E. Dystocia Prolonged, difficult & painful labor Does not result in dilation or effacement Exhausts woman & predisposes to death

Causes of Dystocia 1.Uterine inertia 2.CPD 3.Abnormal fetal positions or presentations

Management for Abnormal Positions & Presentations…. 1.Version (Leopold’s Maneuvers) 2.Forceps assisted delivery 3.Vacuum assisted delivery 4.C/S

F. Cord Problems A.Prolapsed Cord  umbilical precedes the baby  Serious complication  May cut off fetal circulation  Requires emer. C/S

Nuchal Cord Cord wrapped around neck If discovered before labor, C/S is done *If not, forceps are used to speed delivery & cord cut immediately

Other Considerations of Labor & Delivery

The Induction Process Drugs may be administered parenterally, orally, or vaginally Oxytocin most common (PGE) Prostaglandin E  (Cervidil) Amniotomy

Nursing Care during Induction 1.Note the time of amniotomy, color & amount of fluid 2.Monitor fetus for signs of distress 3.VS q min. then q 30 min. fol. Rupture of membranes

Emergency Delivery  Never to be delayed  Remain calm & deliver baby  Follow aseptic technique  Double tie cord  Keep baby warm, ensure breathing

Cesarean Delivery Post Op Care

Assess VS Observe lochia, incision & fundus I & O for hrs Advance diet as tolerated

Perineal care Early ambulation & breathing exercises

CRITICAL THINKING QUESTION A patient is in her third trimester and informs the nurse during her prenatal visit that she is experiencing constipation and stress incontinence. The patient asks the nurse how she can manage these problems. What information should the nurse provide for this patient?