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Labor and birth process
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Labor Process Exact mechanism unknown Theories: Uterine stretching
Prostaglandin Oxytocin stimulation Cervical pressure Aging placenta Increased fetal cortisol levels
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Signs of labor Lightening Increased level activity Weight loss
Braxton hicks contractions Cervical changes Uterine contractions Bloody show Rupture of membranes
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True labor verses False labor
Differentiated ONLY by cervical changes: Dilation Effacement
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Components of labor Passage Passenger Power Psyche Placenta
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Passage Route fetus must travel from uterus to perineum
Shape of pelvis Gynecoid Anthropoid Android Platypelloid
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Passage Bony structures Pelvic diameters Soft tissues Joints, bones
False pelvis True pelvis Pelvic diameters Diagonal conjugate Soft tissues
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Passenger Fetal skull Bones Suture lines Fontanelles Diameter Molding
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Passenger Presentation – fetal body part that will be first to pass through cervix Affects duration and difficulty of labor Affects method of labor Describe as variations of: Cephalic- vertex, brow, sinciput, mentum Breech – complete, frank, incomplete, footling Shoulder – shoulder, iliac crest, hand, elbow
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Passenger Lie – refers to relationship of long axis (spine) of fetus to long axis of mother Longitudinal Cephalic, breech Transverse Horizontally, side to side Oblique 45 degree angles
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Passenger Attitude Complete flexion – chin to chest
Moderate flexion – military Partial extension – brow Complete extension - face
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Passenger Position – relationship of presenting part of fetus to specific section of mother’s pelvis Patient’s pelvis – 4 sections Right anterior Left anterior Right posterior Left posterior Fetus parts – Occiput (O)– vertex Mentum (M)- face Sacrum (S) – breech Acromion (A) - shoulder
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Passenger position Fetal position described by using three letters:
First letter defines whether fetal landmark pointing to mother’s right or left Second letter designates fetal landmark Occiput(O), mentum(M), sacrum(Sa), Acromion(A) Last letter defines whether landmark points anteriorly(A), posteriorly(P), or transverse(T) LOA – left occiput anterior most common
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Passenger Station – relationship of presenting part to ischial spine of mother -5 (pelvis)to +4(perineum) Station 0 is at level of ischial spines – engagement occurs Floating, ballotable crowning
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Cardinal movements of labor
Number of fetal position changes as travels through birth canal Engagement Decent Flexion Internal rotation Extension External rotation Expulsion
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Power Force of uterine contractions Contractions of abdominal muscles
Contraction pattern Begin pacemaker point upper uterine segment Wavelike pattern relaxation Phases: Increment Acme Decrement Duration Contour changes
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Power Cervical changes – increased diameter of cervical canal and lumen occurs by pulling cervix up over present part with uterine contractions Effacement – shortening and thinning of cervical canal % to 100% Dilation – enlargement of cervical canal from 1 to 10cm
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Psyche / Psychological Response
Feeling woman brings to labor Psychological readiness for labor Factors affecting Preparation Support person Past experiences Task of pregnancy Situational control
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Maternal Position Philosophy of Childbirth Partners Patience Patient Preparation
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Maternal physiologic response to labor
Cardiovascular Fluid and electrolyte Respiratory Hematopoietic GI Renal Musculoskeletal neurologic
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Fetal Response to Labor
Healthy fetus adapts to stress of labor Periodic fetal heart rate changes Circulation Increase PCO2 Decrease Partial PO2 Decrease fetal breathing movements
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Stages of labor Dilation – 0 to 10 cm Expulsion Placental
Immediate postpartum
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Dilation Begins with true labor contractions ends with complete cervical dilation Divided into 3 phases 1. Latent: 0-3cm 2. Active: 4-6cm 3. Transitional: 7-10cm
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Latent Phase Preparatory phase Contractions mild and short 30-40sec
Dilation 0-3cm 4-6 hours Analgesia too early prolongs phase Walking, packing, preparing
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Active Phase Working phase 4-6cm
Contractions stronger, sec, every 3 to 5 min True discomfort 2-4 hours Rupture of membranes Analgesia little effect on progress of labor
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Transition phase Feeling of loss of control occurs here 7-10cm
Contractions peak intensity 2-3 min 90 second duration Feelings of urge to push Intense discomfort, nausea, vomiting, anxiety, panic, irritability Focus inward on task of birth
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Expulsion Full dilation and effacement to birth of infant
20 min to 2 hours Fetus moved by “cardinal movements of labor Uncontrollable urge to push with contractions 2-3 min n/v, perspires, distended blood vessels, petechae Perineum bulge Inverted anus crowning
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Placental Birth of infant to delivery of placenta Placental separation
Bleeding on maternal side Lengthening of umbilical cord Gush vaginal blood Change shape of uterus Presentation: Shiny schultz Dirty duncan
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Immediate post-partum
3 hours after delivery Stabilizing Mom Bleeding, bp, perineum, uterus, pain Stabilizing baby Acclimated extrautering life Promoting bonding
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Nursing Management Nursing Management during labor and birth
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Assessments Maternal Vaginal Exam - Dilation, effacement, station, membranes Contraction pattern
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Contraction patterns Phases Duration Frequency intensity
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Assessments Fetal Position – Leopold’s maneuvers Amniotic fluid
Electronic fetal monitoring Intermittent Continuous External Internal
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Fetal heart rate patterns
Baseline Fetal Heart Rate Baseline variability Increased variability Decreased variability
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Periodic Baseline Changes
Accelerations Decelerations Early Late Variable
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Other Fetal Assessment Methods
Fetal Pulse Oximetry Fetal Stimulation Scalp Ph
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Providing comfort Etiology of pain Perception Fetal position
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Nonpharmacologic Measures
Labor Support Ambulation / Position Changes Acupuncture / pressure Focused Imagery Breathing Techniques Therapeutic touch / Massage Effleurage
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Pharmacologic Systemic Regional Local General IV, IM, PO Epidural
Spinal Regional block Local General
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Nursing Care Admission assessment Continual Assessment First Stage
Second, Third, Fourth Stage
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Nursing care VS I&O Pain Emotional support Sterile technique Teaching
cleanliness
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Nursing care calm environment Clear liquids Output Ambulate
Involve support person IV-blood samples Position changes Breathing techniques Perineal care Monitor contractions Monitor FHR VE
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Nursing Care During First Stage of Labor
General measures Obtain admission history Check results of routine laboratory tests and any special tests Ask about childbirth plan Complete a physical assessment Initial contact either by phone or in person
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First Stage of Labor: Phone Assessment
Estimated date of birth Fetal movement; frequency in past few days Other premonitory signs of labor experienced Parity, gravida, and previous childbirth experiences Time frame in previous labors Characteristics of contractions Bloody show and membrane status (whether ruptured or intact) Presence of supportive adult in household or if she is alone
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First Stage of Labor: Admission Assessment
Maternal health history Physical assessment (body systems, vital signs, heart and lung sounds, height and weight) Fundal height measurement Uterine activity, including contraction frequency, duration, and intensity Status of membranes (intact or ruptured) Cervical dilatation and degree of effacement Fetal heart rate, position, station Pain level
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First Stage of Labor: Admission Assessment (cont’d)
Fetal assessment Lab studies Routine: urinalysis, CBC HbsAg screening, GBS, HIV (with woman’s consent), and possible drug screening if not included in prenatal history Assessment of psychological status
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First Stage of Labor: Continuing Assessment
Woman’s knowledge, experience, and expectations Vital signs Vaginal examinations Uterine contractions Pain level Coping ability FHR Amniotic fluid
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Nursing Management: Second Stage
Assessment Typical signs of 2nd stage Contraction frequency, duration, intensity Maternal vital signs Progress of labor, crowning Fetal response to labor via FHR Amniotic fluid with rupture of membranes Coping status of woman and partner
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Nursing Management: Second Stage
Interventions Supporting woman & partner in active decision-making Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced Providing instructions, assistance, pain relief Using maternal positions to enhance descent and reduce pain Preparing for assisting with delivery
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Nursing Management: Second Stage
Interventions with birth Cleansing of perineal area and vulva Assisting with birth, suctioning of newborn, and umbilical cord clamping Providing immediate care of newborn Drying Apgar score Identification
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Nursing Management: Third Stage
Assessment Placental separation; placenta and fetal membranes examination; perineal trauma; episiotomy; lacerations Interventions Instructing to push when separation apparent; giving oxytoxic if ordered; assisting woman to comfortable position; providing warmth; applying ice to perineum if episiotomy; explaining assessments to come; monitoring mother’s physical status; recording birthing statistics; documenting birth in birth book
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Nursing Management: Fourth Stage
Assessment Vital signs, fundus, perineal area, comfort level, lochia, bladder status Interventions Support and information Fundal checks; perineal care and hygiene Bladder status and voiding Comfort measures Parent-newborn attachment Teaching
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