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Labor and Birth Process and Nursing Management Chapter 13 & 14
Mary L. Dunlap MSN Fall 2015
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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.
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Possible Causes of Labor Maternal
Uterine muscle stretching Pressure on the cervix Oxytocin Placental aging Estrogen/Progesterone ratio change Fetal cortisol concentration Prostaglandins
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Possible Causes of Labor Fetal
Placental aging Fetal Cortisol concentration Prostaglandin
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Signs Preceding Labor Energy burst Lightening
Braxton-Hicks contractions Weight loss Bloody show Lightening Increase vaginal discharge Cervix softening Rupture of membranes
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False Labor Does not cause cervical change Irregular contractions
Activity does not increase contractions Sedation will stop or decrease contractions Irregular contractions No regular pattern Discomfort in lower abdomen and groin Show is not present
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True Labor Activity increases contraction frequency
Sedation does not diminish contraction pattern Causes cervical changes Show usually present Regular contractions Contractions Progresses to a pattern Discomfort begins in back and radiates to the abdomen
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Factors That Affect Labor
The Five P’s: Passageway (birth canal) Passenger (fetus and placenta) Powers (contractions) Position of the mother Psychologic response
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Passageway Pelvic structure and shape Soft tissues cervix Pelvic floor
Vagina
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Passenger Size of the fetal head Presenting part Fetal lie
Fetal attitude Fetal position
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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
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Fetal Skull Figure 13-3 p.399
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Passenger: Presenting Part
Cephalic Breech Frank Full or complete Footling or incomplete Shoulder Fetal presentation- fetal part enters pelvic inlet 1st
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Breech Presentations
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Fetal Lie Fetal lie is the relationship of the spine of the fetus to the spine of the mother Longitudinal Transverse Go to next slide and use picture and mannequins to discuss concept
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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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fig 13.9 pg. 402
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Powers Contractions primary force Frequency Duration Intensity
Pushing secondary force
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Maternal Position Affects woman’s anatomic and physiologic adaptations to labor Frequent changes in position Relieve fatigue Increase comfort Improve circulation Facilitates decent and rotation
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Psychological Response
Factors 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
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Factors That Affect Labor
5 Additional P’s Philosophy Partner Patience Pain management
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Cardinal movements of Labor
Engagement Descent Flexion Internal rotation Extension External rotation (restitution) Expulsion (birth)
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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%
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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
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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
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Doppler
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Doppler
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Continuous Fetal Monitoring
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Contraction Assessment
Frequency Duration Strength/Intensity Resting tone
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Contraction Phases
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Pelvic Exam Effacement Dilation Presenting part Station
Status of membranes
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New classifications -5 to +5 measured in centimeters now
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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
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Leopold’s Maneuver Video12310
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Physiologic Adaptation to Labor
Maternal Adaptation Cardiovascular changes Respiratory changes Musculoskeletal changes Gastrointestinal changes
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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
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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
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Monitoring Techniques
Electronic fetal monitoring External monitoring FHR—ultrasound transducer UCs—Toco transducer Internal monitoring (invasive) Spiral electrode (FSE) Intrauterine pressure catheter (IUPC)
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Amnio Hook
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Fetal Scalp Electrode
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Placement of FSE
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IUPC
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Internal Fetal Monitoring
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FHR Categories Category I normal Category II indeterminate
Category III Predictive of abnormal fetus acid base status Tab pg.429 Developed to have effective clinical communication about variant FHR patterns Preventing miscommunication between professionals & To promote maternal fetal safety Category I normal no intervention required Category II indeterminate requires evaluation and continued monitoring Category III Predictive of abnormal fetus acid base status requires prompt evaluation and interventions
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Determining FHR Patterns
Fetal assessment Baseline FHR Variability Accelerations Periodic changes (decelerations) Early (head compression) Late (placental insufficiency) Variable (cord compression)
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Baseline Fetal Heart Rate
Baseline Rate is the average FHR that occurs during a 10-minute segment excluding periodic or episodic rate changes Normal Bradycardia <110 Tachycardia >160
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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
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Fetal Heart Rate Patterns
Changes in fetal heart rate Periodic occur with Contractions Episodic (non-periodic) not associated with contractions Accelerations Decelerations
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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
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Decelerations Early decelerations Late decelerations
Variable decelerations Prolonged decelerations
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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
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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 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
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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
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Decelerations
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Fetal Heart Rate V Variable E Early A Acceleration L Late C Cord
H Head Compression O Oxygenated fetus P Placental problems
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Fetal Assessment Methods
Umbilical Cord Blood Analysis Fetal Scalp Stimulation
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Pain Management Nonpharmacologic Pharmacologic
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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
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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) Nonpharmacologic Management
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Pharmacologic Management
Systemic Analgesia Regional Analgesia/Anesthesia
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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
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Systemic Analgesia Opioids Ataractics/Antiemetics Benzodiazepines
Drug Guide 14.1 pg. 441
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Regional Analgesia/Anesthesia
Pudendal never block Epidural (Vaginal Del or C/S) Spinal (C/S) General (C/S)
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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
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Epidural Analgesia
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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
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Epidurals/Spinals/General Anesthesia
Anesthesia interview Consent form Labs (platelets less than 100,000 can place an epidural/spinal)
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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
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Second Stage of Labor Assessment of contractions and FHR Fetal descent
Psychological considerations Maternal positioning Coaching maternal breathing and pushing efforts
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Preparation for Delivery
Prepare instrument table Adequate lighting Oxygen and suction equipment Radiant warmer, blankets, identification for newborn Pitocin
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Delivery Table
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Preparation for Delivery
Positioning of mother for birth Gown, gloves, and protective equipment for personnel Cleansing of the perineum Deliver the newborn
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Second Stage of Labor Perineal Lacerations (Depth) * 1st degree
* 2nd degree * 3rd degree * 4th degree Episiotomy * midline * mediolateral
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Third Stage of Labor Delivery of the placenta
Assess for perineal trauma Repair of episiotomy/Perineal lacerations Newborn care Emotional support /Foster bonding
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Episiotomy
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Episiotomy Repair
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Apply ice pack as soon as possible
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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
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Fetal Side Shinny Schults
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Maternal Side Dirty Dunkin
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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
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Apgar Score Assessment 0 Point 1 Point 2 Point Heart Rate Absent
< 100 bpm > 100 bpm Respiratory effort Apneic Slow, irregular, shallow Regular 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 A= appearance (color) P = pulse (heart rate) G = grimace ( reflex irritability) A = activity ( muscle tone) R = respiratory ( respiratory effort)
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Apgar Score
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Fourth Stage of Labor Maternal Assessment Uterus Lochia Perineum
Bladder Vital signs Pain Newborn-family attachment Breastfeeding initiated
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