Week 8 Lecture

Chapter 22--Processes & Stages of Labor and Birth

1Critical Factors In LaborThe Four Ps: passage, passenger, powers & psyche

Passage: adequate pelvis?cephalopelvic disproportion (CPD)Suspect if presenting part does not engage in pelvis (0 station)2PassengerThe fetus: head is largest diameterFetal head: 4 bones with 3 membranous interspaces (sutures) that allow bones to move & overlap to diminish size of skullMolding: head becomes narrower, longer, sutures can overlap--normal--resolves 1-2 days after birthFontanelles: at junctures of skull bones3

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Fetal Attitude5Fetal Lie and PresentationLeopold's maneuvers/USLongitudinal lie: Vertical Presenting part: cephalic (head), vertex (occiput), chin (mentum) breech (buttocks or feet) (c-section)sacrumTransverse lie: Horizontal (c-section)Presenting part: shoulder (acromion)

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Fetal position: moms pelvis is divided into 4 quadrants: RA, RP, LA, LP

determine which quadrant presenting part (occiput) is pointing towards7PassengerOcciput Anterior (LOA & ROA): most common positions & easiest for birth

Occiput Posterior (LOP & ROP): can prolong both 1st & 2nd stage of laborback pain during UCs (back labor)Instruct partner in sacral pressure during UCsTry all fours, knee-chest, or alternate side-lying positions to encourage baby to rotate to anterior position8PowersContractions: supplied by fundus of uterusInvoluntary, become stronger as labor progressesAbdominal muscles: pushing by mom (2nd stage)

PsychePsychological state & feelings of momCoping skillsAnxiety, fear, stressLabor support9Onset of laborUsually begins between 38 & 42 weeksMechanism is unknownUpper uterus contracts downward pushing presenting part on cervix causing effacement and dilatationPremonitory signs of labor:Lightening, Braxton-Hicks contractions (false labor),cervical changes (ripening), bloody show (mucous plug), rupture of membranes (ROM), sudden burst of energy10False vs True Labor: Contractions False Labor Benign and irregular contractions

Felt first abdominally and remain confined to the abdomen and groinOften disappear with ambulation and sleep.Do not increase in duration, frequency or intensity True Labor:Begin irregularly but become regular and predictableFelt first in lower back and sweep around to the abdomen in a waveContinue no matter what the womens level of activityIncrease in duration, frequency, and intensity

11False vs True Labor: Cervix False LaborNo significant change in dilation or effacement

No significant bloody show

Fetus- presenting part is not engaged in pelvis True LaborProgressive change in dilation and effacement

Bloody show

Presenting part engages in pelvis

12Critical ThinkingA primigravida client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus?

A. Check for ruptured membranes, and apply a fetal scalp electrode B. Auscultate the fetal heart rate between and during contractions C. Palpate contractions and resting uterine tone D. Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers E. Determine gestational age of fetus 13Stages of Labor: First Stage 0 to 10 cm: dilatation--opening of cervix)Latent: slowest part of the process--slow dilation, mild contractionsfrom onset of regular UCs to rapid dilatation (about 3-4 cms)Active: labor picks up steam--period of more rapid dilationfrom 4 cm to full dilatation: stronger UCsTransition: 7-10 cm--intense, N/V, shaking

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EffacementThinning of cervix(in %)StationDescent of fetal head(in cm)15

Descent offetal head:

StationFloatingEngagedAt outlet/crowning16

17Dilatation & Effacement

18Care of Laboring PatientEarly LaborInitial physical assessment & historyAdmission--rapportFetal & UC monitoringVaginal exams, q 2 hoursVital signsTemperature q 4 hours-intact or q 2 hours ROM

Educate regarding laborEncourage comfort, position changes, bladder emptyingAssess pain, pain tolerance, preferred type of labor/deliveryReassure regarding what is normal, reduce anxietyCouple excited, talkative, pain is manageable19Care of Laboring Patient Active LaborTransition (7-10 cm): Yikes! out of control, shaking, nausea/vomiting, sweating, pain is intensePrepare for deliverySecond stage (Pushing):Educate/instruct regarding pushingAssess urge to push and fetal descentEncourage/motivate patient, assess fatigueMonitor fetal/maternal response to pushing bulge, crowningSigns of imminent birth: perineal bulging

Couple quieter, discouraged, pain increasing20Stages of Labor:Second Stage Pushing & descent of baby (STATION)Full dilatation (10 cm) to birthImportant NOT to push until full dilationAssessment: Urge to push? Rectal pressure?Push only with UCsCrowning: babys head is visible at the opening of vaginaCardinal movements of labor youtube.com/watch?v=Xath6kOf0NE&feature=related youtube.com/watch?v=duPxBXN4qMg&feature=related

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Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.22Head Rotation during Descent

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CrowningIn the hospitalAlternative settings

Crowning24Stages of Labor: Third StagePlacental stage: from birth to delivery of placentaPlacental separation from uterine wall (rise of fundus, sudden gush of blood, lengthening of umbilical cord)Entire lining of uterus shedExpulsion of placentaNormal blood loss: 300-500 mLIf placenta does not deliver spontaneously, can be delivered manuallyPitocin infusion started immediately post delivery of placenta

25Critical Thinking

A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds. The client is apprehensive and vomiting. This nurse understands this information to indicate that the client is most likely in what phase of labor?

A) Active B) Transition C) Latent D) Second

26Methods of InductionProstaglandins (Cervidil, prostin gel, Prepidil, Cytotec) applied intravaginally for cervical ripeningPitocin (oxytocin) by IVAmniotomy or stripping of membranesSexual intercourseNipple stimulationHerbal preparations

27Indications for induction of laborPost-term pregnancy ( 42 weeks)Premature or prolonged rupture of membranesMaternal complications (Rh isoimmunization, Diabetes, Pulmonary disease, Pregnancy-induced hypertension)ChorioamnionitisSuspected fetal problems- Intrauterine Growth restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)Fetal demise28Contraindications to Inductionprevious c-section placenta previa or abruption prolapsed cordfetal bradycardia, nonreassuring fetal statusvaginal bleeding of unknown causecephalopelvic disproportionactive genital herpes29Cervical Ripening AssessmentBishop Score- rating that determines if the cervix is ready for inductionFetus must be in vertex positionBaseline data on fetal and maternal well-being (at least half an hour of monitoring)Fetal monitoring and uterine contraction monitoring is imperativeNotify MD if hyperstimulation or fetal heart rate distress is noted30Oxytocin Induction

Confirmation that the baby is in a cephalic (vertex) position (head down) V/S done at least every 30 minutes and when dose is titratedFHTs and UCs assessed every 30 minutesTitration of oxytocin till UCs every 2-3 minutesCervical dilation should be 2 cm/hr (ideally)Reassuring FHTs between 110-160 beats/min

31When to Discontinue OxytocinHyperstimulation-frequency of UCs less than 2 minutes apart -Now being called tachysystole -Inadequate uterine relaxation between contractions 42 weeksMaternal risks: trauma/hemorrhage due to larger baby, operative delivery/c-sectionFetal risks: placental changes that oxygenation to baby and mortality rate, oligohydramnios (cord compression during labor), LGA baby (birth trauma, shoulder dystocia), meconium aspirationManagement: > 40 wks, NST, BPP or modified BPP (NST & AFI), induction36MalpresentationsOcciput-posterior (OP) Prolonged labor, back labor (sacral nerve compression), arrested dilatation/ descent, perineal tearsUsually vaginal, but may need C-Section if baby doesnt rotateManagement: positioning (side-lying, knee-chest or hand-knees), sacral pressure during UCsTransverse LieAssociated with: pendulous abdomen, uterine masses/fibroids, congenital abnormalities of uterus, hydramniosAttempt External Cephalic Version, if unsuccessful obligatory C-section

37Malpresentations (cont)Breech presentationAssessment: FHT heard high on the abdomen, Leopolds, vaginal exam & US.Higher risk of anoxia from prolapsed cord, traumatic injury to the after coming head, fracture of spine or arm, dysfunctional labor

Usually delivered by C-section

38External VersionExternal cephalic version (37-38 wks): abdominal manipulation to change fetal presentationContraindications: multiple gestation, fetal breech is engaged in pelvis, oligohydramnios, nonreactive NST, nuchal cord, vaginal bleeding, IUGR, ROM.Risks: immediate cesarean birthNursing actions: NPO 8 hrs, NST, IV line, terbutaline, continuous FHR, US used to guide manipulations, assess for: labor, fetal distress. O- moms need Rhogam following the procedure

39Macrosomia/Shoulder DystociaWt. > 4500 gms (9-10 lbs)Associated with:DM, Gestational DM, Multiparity, Postdates, obesityRisks: Shoulder dystocia, difficulty delivering the shoulders after head is delivered (obstetrical emergency)Maternal: vaginal/cervical tears, pp hemorrhage, ruptureFetal: compressed cord, fractured clavical, asphyxia & neurologic damage, brachial plexus injury (ErbsPalsy)S/S: Turtle signNursing interventions: McRoberts maneuvers, suprapubic pressure. PP: assess for uterine atony/hemorrhage; trauma, cerebral or neurologic damage to baby40

Video: youtube.com/watch?v=jV6g427UMxY&feature=related

41McRoberts Maneuvers Video

42Multiple GestationMonozygotic (identical) twins: can have 1 or 2 placentas, chorions, or amnions (risk if all shared)Dizygotic (fraternal) twins: 2 of everything.

Dx: faster than usual growth of uterus, AFP, HCG, UltrasoundRisks: Maternal: SAB, gestational DM, HTN/preeclampsia/HELLP, hydramnios, PT labor & deliveryFetal: Preterm birth, twin-to-twin transfusion43Multiple Gestation (cont)Management:US to determine what type of twinsPrevention of PT labor/routine cervical measurements (US)NST surveillance Birth: depends on maternal & fetal complications and fetal position/ presentationExamination of placentaClose monitoring PP for hemorrhage (atony)44Abruptio PlacentaePremature separation of placenta from uterine wallS/S: sharp, stabbing pain high in fundus, heavy bleeding (may be occult), hard, board-like uterus, tense, painful uterus, signs of shock due to blood loss, Port-Wine aminotic fluid if ROM.Predisposing fx: parity, adv. maternal age, short umbilical cord, chronic HTN, PIH, direct trauma, vasoconstriction from cocaine or cigarette use Fetal distress on monitor. Can progress to DIC.45

46Abruptio Placentae (cont)Management: Emergency. Immediate c-section if birth not imminent.Lg. gauge IV O2 via mask, fetal monitoring, maternal VS, lateral positioning, labs, blood transfusion (have 2 units avail)CBC (H&H), Fibrinogen levels, platelet count, PT/PTT, fibrin degradation products ( sx of DIC)

47Placenta PreviaLow implantation of placenta (1 in 200)abrupt, painless, bright red bleeding

Associated with parity, adv. maternal age, previous c-section or uterine curettage, multiple gestationDx: ultrasound. May resolve as pregnancy progresses.Bleeding common around 30 wks: Bedrest, VS, IV fluids, type & cross-match, observe for bleedingEmergency: assess bleeding, hx, ucs/labor, NEVER do vaginal exam !!! C-Section delivery, possibly before 37 wks. Steroids for mom. Watch for pp hemorrhage.

Differential dx: abruptio/previa48

Low-lyingMarginalPartialCompletePlacenta Previas49Prolapsed CordLoop of umbilical cord slips down in front of the presenting partS/S: deceleration of FHT: bradycardia, persistent variable decels, cord palpatedor seen in vagina

Associated with:Premature rupture of membranesTransverse or breech presentationMultiple gestationPlacenta previaHydramniosCPD (non-engagement of fetal head)

50Prolapsed CordManagement: Hold fetal head off cord, Trendelenburg or knee/chest position, immediate emergency c-section

PreventionWatch fetal heart tones after rupture of membranes (SROM or AROM). Do VE if any sign of fetal distress.If head not engaged, women with ruptured membranes should not ambulate.

51Birth Related Procedures

Induction of laborThe deliberate initiation of uterine contractions, by chemical or mechanical means, to stimulate labor and birth before spontaneous onset of labor

Primary agent of induction: Pitocin by IVPitocin is also used to augment labor

If cervix not ripe, may need a preparatory stage of cervical ripening before pitocin can be started Cervidil

52Operative Assisted DeliveriesForcepsIndications: unable to push, arrested descent, need a quick delivery, breechAssociated with: maternal/fetal birth trauma, rectal sphincter tear, urinary stress incontinenceVacuum extractionAdvantages: fewer lacerations, less anesthesia needed,Disadvantages: marked caput, cephalhematomas, scalp laceration/bruising53

54Experiences of PainEtiology PhysiologyPerceptionFactors influencingAnxietyPsychological factorsExpectationsCultural factorsSupport Fetal position55Comfort and Pain ReliefSupport from doula or coachAlternative therapiesRelaxation/massageFocusing and imageryBreathingHerbal preparations/aromatherapyHypnosis56Comfort and Pain ReliefPharmacological MeasuresNarcotic analgesicsNubain/Stadol/Demerol (pg. 689)Regional nerve blocksEpidural/spinalLocal anesthetic blocksPudendal/perineal

57Systemic Analgesia

Pre-medication Assessment: Pain level, VS, allergies, drug dependence (withdrawal), vaginal exam/progress in labor, UC pattern, fetal heart rate tracingPost-medication Assessment:VS, esp. RR, LOC, dizziness (bedpan), sedation, FHRReversal agent: Naloxone (Narcan)Competes with narcotic for opiate receptors. Used in both mom and baby. (avoid with narcotic dependence)58Regional AnesthesiaInjection of local anesthesia to block specific nerve pathwaysEpidural/spinal anesthesiaSystemic toxicity: cardiovascular collapseSide effects: Hypotension (preload with IV fluids), fetal distress on FHR tracing, spinal HAContradindications: coagulation disorders, low platelet count (< 100), allergy, neurologic disease, aspirin useNursing care: Preload IV fluids (LR), monitor BP, HR, anesthesia level, FHR, foley cath, maternal positioning59

Epidural Anesthesia60Medication for Pain Relief: BirthLocal anesthesiaPudendal nerve block (2nd stage, episiotomy, repair)Local infiltration in perineum (episiotomy, repair) General anesthesiaRegional contraindicated/emergencyPreparation: hip wedge, preoxygenation, cricoid pressure for intubationComplications: fetal depression, aspiration of vomitus (Bicitra)

61Local anesthesia for Episiotomy

62Cesarean BirthIndications for:Maternal FactorsActive genital herpesAIDS/HIV +Cephalopelvic disproportionSevere preeclampsia, diabetesObstructive tumorRuptured uterusPrevious c-sectionFailed induction/fx to progress in laborElective?

Placenta FactorsPlacenta previaPlacental abruptionUmbilical cord prolapse

Fetal FactorsBreech, transverse lieMacrosomiaExtreme low birth wtFetal distressFetal anomaliesMultiple gestation63Cesarean Birth (cont)Mortality/morbidity4 x higher than vaginal birth in US. Most risk assoc. with emergency c-section

IncisionSkin vs. uterineClassical vs low transverseMaternal ComplicationsInfectionAnesthesia reactionsDeepVeinThrombophebitisBleedingUreteral/bladder injuryIncrease risk for subsequent pregnancyPlacenta Acreta/Previa, Infertility64

65Cesarean BirthPre-op: CBC w/ platelets, hold clot,bicitra/antacidmonitor babyTeaching: pre & post-op, anesthesia, recovery, breastfeedingPsychosocial issues:FearSelf-image/self-esteem66Post-Op CareAssess fundus/bleeding, vital signs, DVT.Antibiotics. Pain: Duramorph. Breakthrough pain meds. Benadryl for itching. Zofran for nausea.Clear liquids and advance as tolerated.Assess for GI function. Bowel sounds? Passing flatus?Ambulation. Pre-medicate, teach splinting with pillow.Stool softener67Critical ThinkingA laboring multipara is having intense uterine contractions with incomplete uterine relaxation between contractions. Vaginal examinations reveal rapid cervical dilation and fetal descent. What should the nurse do first?

A) Notify the physician of these findings. B) Place the woman in knee-chest position. C) Turn off the lights to make it easier for the woman to relax. D) Assemble supplies to prepare for birth.

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