the abcs of l&d and nursing care (1)

7/31/2019 The ABCs of L&D and Nursing Care (1)

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The ABCs of L&D and Nursing

Care


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Historical overview of childbirthWhere/how did your mother/grandmother/oldest relative deliver?

Biblical times to late 1800s

CB natural part of daily living Women help other women

Lay midwives were the norm

Home birth was the norm

Pain managed through natural remedies

Risk factors were related to poor nutrition, health, lack

of skilled midwife, hygiene and poor conditions


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1900s through mid 1960s

Increase in male physicians role in childbirth

Medical advances brought pain relief options

Hospital setting became the norm Mother isolated from husband during labor

Safer births brought fewer childbirth related deaths

Most moms were stay at home

Hospital length of stay was 5-7 days


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Late 1960s to now

Womens movement increased awarenesspersonal

choice

NCB (natural childbirth) back as option

Medical technology advances continue

Women working outside home the norm superwoman ideal praised and questioned

Birth centers/birth plans options now

Midwives (CNMs) again an option

SO/fathers role important as support

Health insurance influences choices made

Questions re: high or low tech birth-what is best?

Shorter hospital stays (2-3 days norm)


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How does labor begin?

Usually begins between 38 and 42 weeks (term),

following lightening, nesting, often SROM

Many theories

Uterine overdistention theory (might explain why twin, triplet

etc. gestations tend to deliver early)

Progesterone withdrawal (progesterone keeps the uterus

relaxed, but blood levels at time of labor are decreased)

Prostaglandin production (prostaglandin stimulates the

uterus to contract-levels found to be higher in labor)

Increase in water content of cervix- softens it and then it

begins to thin (efface) and open (dilate)


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The 5 Ps all influence labor(passage, passenger, powers, psyche, position)

Passage (1stP)

True pelvis is the bony canal through which the

fetus must pass

Estimates of pelvic

adequacy (measurements) are made during an early

prenatal visit and may influence delivery type (vag or c/s)


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Types of Pelvis(Olds, 2012, p.530)

Gynecoid-most common type female pelvis, inlet is rounded(50% of women have this-most favorable for vaginal delivery)

Android-normal male pelvis, occasionally seen in females, inletis heart shaped (seen in about 20% of women, generally not

favorable for vaginal birth)

Anthropoid-the pelvis is oval (seen in about 25% of women,may or may not be adequate for vaginal delivery)

Platypelloid-the pelvis is flattened (seen in about 5% ofwomen, not favorable for vaginal birth)


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Name that type of pelvis!


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Passenger (2ndP)

Fetus

Fetal head

Sutures & fontanelles

Fetal landmarks

Do you remember the landmarks

on the fetal/NBN head?!

Feel the landmarks on a

newborn in clinical! Why dosome have overlapping sutures?

Which sutures are most likely to

overlap?


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Fetal Attitude The relationship of the fetal parts to one another; the normal attitude is flexion

of the neck, arms and legs

Other types of attitude What type of attitude is this?


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Fetal Lie

The relationship of the longitudinal axis of the fetus

to the longitudinal axis of the mother

Vertex (head first) is most common

Which picture below would be most conducive to vaginal

delivery? Which would be termed a facepresentation?
http://cats.med.uvm.edu/cats_teachingmod/ob_gyn/teaching_modules/normal_delivery/movies/lie1.dcr


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Other fetal lies

Fetal lie could also be

Breech Complete

Incomplete

Frank

Transverse Oblique


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Fetal Presentation

The fetal part entering the pelvis first

Most common is cephalic (head first), but

breech and shoulder are also possible

Whatbody part

is coming

out firsthere?
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/23824_2382IMG003.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/23824_2382IMG003.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/23824_2382IMG003.jpg&template=izoom2


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Breech presentation

occurs when the fetus presents 'bottom-down' or sideways

in the uterus. Here are three types:

Breech with extended legs (frank) - 85% cases

Breech with fully flexed legs (complete) Footling (incomplete) with one or both thighs extended

The significance of breech presentation is its association

with higher perinatal mortality and morbidity when

compared to cephalic presentations. This is due both topre-existing congenital malformation, increased

incidence of breech in premature deliveries and

increased risk of intrapartum trauma or asphyxia.


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Fetal Position Refers to the relationship of the fetal

presenting part to the maternal pelvis Portrayed with a 3 letter notation

RorL is the first letter, indicating which side of

the maternal pelvis the presenting part istoward

The second letter indicates the landmark of the

fetal presenting part

O=occiput (back of head)

M=mentum (chin)

S=sacrum (butt)

A=acromion process (shoulder)


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Fetal Position Continued

The third letter indicates the relationship ofthe presenting part to the front, back orside of the pelvis

A=anteriorP=posterior

T=transverse

The most common positions at delivery areROA orLOA (see Olds, 2012 p. 536)


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Practice determining position with

diagrams below and soft model


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Problems with and how to prevent a

posterior back labor
http://www.bing.com/images/search?q=knee+chest+position+diagram&FORM=IGRE1


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Engagement

Occurs when the largest diameter of the

presenting part reaches the pelvic inlet

and can be detected by vaginal exam

Engagement is referred to as either

Floating

Ballottable

Engaged


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Station The relationship of the presenting part to

the ischial spines of the pelvis Measured in centimeters above (-1 to -5

station) at (0 station) or below (+1 to +4

station) the ischial spines


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Station


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What does shes crowning mean?


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What should you do if a woman is

crowning (grocery store, elevator,home, labor room) and you are the

only one there?


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Powers (3rdP)

Primary forces of labor (contractions)

Involuntary contractions of uterine muscle

fibers


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Increment-building up of contraction

Acme-peak of contraction Decrement-letting up of contraction

Nadir-resting tone in between contractions


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Frequency of Contractions

Timed from the beginning of one

contraction to the beginning of the next

contraction in minutes


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Contractions continued

Intensity (strength at acme)

Externally (palpating fundus)

Mild (chin)

Moderate (nose)

Strong (forehead) Internally (with IUPC placed)

Measured as mm Hg

Resting tone generally 10-25 mm Hg

Early labor 25-40mm Hg

Active labor 50-70 mm Hg

Transition 70-90 mm Hg

Pushing 70-100 mm Hg


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Duration of Contractions

How long a contraction lasts

Measured in seconds from the beginning

of the increment to the end of the

decrement


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Contractions are generally timed from beg. of one

to beg. of next


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Effacement-thinning of the cervix

0-100%(Primigravidas tend to efface first,

then begin to dilate)


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Dilitation (dilation)-0 to 10 cm


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Dilation

As the uterus elongates with contractions,

the fetal body straightens and exerts

pressure against the cervix, resulting in

dilation, or opening of the cervix.

Dilation is usually measured from 0 (cervix

closed) to 10cm (fully dilated and no cervixpalpable on exam)


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Secondary Powers

Voluntary use of the abdominal muscles

during the second stage of labor to deliver

the fetus (pushing)

purple pushing (closed glottis)

Positions that facilitate fetal descent

Concerns

Non-coached may be optimal in terms of fetaloutcome

Butpurple pushing seems to be the norm


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Psyche (4thP)

The psychological component of

childbearing

Excitement, fear, loss of control, anxiety,

Can be manifested physiologically (e.g.

changes in vital signs)

How can the psyche be most positively affectedduring labor and delivery?


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Position (5thP)

In what position do women commonly

deliver?

What position do you think evidence saysis optimal?

Why dont most women deliver in a mostly

vertical position?

C di l M t


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Cardinal Movements(Olds, 2012, figure 22-11)

Adjustments the fetal head makes in order topass through the birth canal

Every darn fool in Rotterdam eats rotten eggrolls every day

Engagement

Descent

Flexion

Internal Rotation

Extension

Restitution

External rotation

Expulsion

Delivery


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Steps for Nurse delivery during

a precipitous delivery As the head crowns, support the perineum to avoid lacerations and ask the patient to blow or pant

The head will extend and advance

Immediately after the head is out, check for nuchal cord. If loose nuchal cord, unwrap and proceed. If tight

cord, double clamp cord with two hemostats and cut

Suction mouth and nose with bulb syringe

Assist baby to OA position if it does not turn on its own

Deliver anterior shoulder

Deliver posterior shoulder

Deliver the rest of the body

Double clamp and cut the cord if able

Dry and stimulate the infant to cry/breath

Place the infant on mom (skin to skin)

Consider refreshing your deodorant!

If able, note time of birth, time placenta delivered, administer pitocin after placenta delivered or massage fundus.

Allow physician to deliver placenta if able. Begin recovery of mom/baby and on-going assessment.


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Signs of labor

Lightening

Stronger Braxton Hicks contractions

Cervical changes

Bloody show

SROM

Burst of energy (nesting)

Increased back pain

GI symptoms-diarrhea


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True vs. False labor

True Labor

Contractions become stronger, longer and closer

together

Bag of waters may break; call your health care provider

Cervix progressively effaces (shortens) and dilates

(opens)

Increase in mucus and bloody show may be present

Walking increases intensity Discomfort in back and abdomen

Contractions don't go away after rest or activity


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True vs. False labor

False Labor

Contractions may be uncomfortable

Contractions usually don't get closer together or last

longer

Contractions are usually not regular

Cervix shows little or no dilation or effacement

Change in activity, either resting or moving around, may

stop contractions Position change may stop contractions

Discomfort usually only in abdomen


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Stages of labor

First stage (beg. of labor to complete dilation) Latent phase (0-3 cm dilated)

Active phase (4-7 cm dilated)

Transition phase (8-10 cm dilated)

Second stage pushing (complete dilation to

delivery of NBN)

Third stage (delivery of NBN to delivery of

placenta) Fourth stage (recovery-generally 1st hour after

delivery of the placenta)


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Apgar Scoring

Performed by nurse usually, at one and

five minutes after delivery, to evaluate the

physical condition of the newborn at birth

and the need for resuscitation


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Apgar Scoring

Apgar Sign 2 1 0

Heart Rate

(pulse)

Normal (above 100

beats per minute)

Below 100 beats per

minute

Absent

(no pulse)

Breathing

(rate and effort)

Normal rate and effort,

good cry

Slow or irregular

breathing, weak cryAbsent (no breathing)

Grimace

(responsiveness or

"reflex irritability")

Pulls away, sneezes,

or coughs with

stimulation

Facial movement only

(grimace) with

stimulation

Absent (no response

to stimulation)

Activity

(muscle tone) Active, spontaneousmovement

Arms and legs flexedwith little movement

No movement, "floppy"tone

Appearance

(skin coloration)

Normal color all over

(hands and feet are

pink)

Normal color (but

hands and feet are

bluish)

Bluish-gray or pale all

over


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Significance of Apgar Score

Score of 7-10

Score of 4-6

Score below 4


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Assign an Apgar score

A mother arrives in L&D, in active labor with her 6th child.

She states her labor began 30 minutes ago and she

needs to push NOW! She bears down and the newborns

head appears and pops out, quickly followed by the rest

of the body. A nurse lets the mom see the child briefly,then takes it to the radiant warmer where she proceeds to

dry and stimulate the baby. At one minute from the time of

delivery, the baby is dusky with copious secretions

coming from its nose and mouth. Respirations are slowand irregular-the baby is gasping occasionally and sounds

very gurgly. The heart rate is 60 BPM. The baby is

floppy and not really responding to stimulation. What is

the 1 minute apgar score and what should the nurse do

next?


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Which is the most critical assessment?

(Think, Pair, Share)Heart rate?

Respiratory effort?

Tone?

Reflex irritability?

Color?


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NBN Meds in Del Rm

Prevention of eye infection

inch strand of 0.5% Erythromycin ointment

into lower conjunctival surface of each eye within

an hour of birth as prophylactic tx. forNeisseriaGonorrhoea

Prevention of Vitamin K deficiency

bleeding0.5-1 mg vitamin K (Aquamephyton) IM in the

middle third of the vastus lateralis muscle within

one hour of birth to prevent hemorrhage


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Why Vitamin K?

Absence of gut bacterial flora in the newborn at birth, which influence

the production of vitamin K, which promotes liver formation of clotting

factors to reduce the risk for hemorrhage

Why and from where might a newborn hemorrhage?

(Hep B first of 3 injections often also given to NBN in hospital)


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Reminder of 3 major time frames for

performing NBN exam while in the hospital

At delivery-establish baseline and need for resuscitative efforts (ABCs

okay?)

On admission to nursery or postpartum unit (reconfirm stability and/or

need for follow-up)

Prior to discharge (still stable? Baseline normal? Need for follow-up?)


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Nursing Care During the

Stages of Labor


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Common Nursing Diagnoses for L&D

Fear/anxiety r/t discomforts of labor

r/t unknown birth outcome

Compromised family copingAcute pain

Knowledge deficit

Compromised individual coping

Altered family processes

Risk for injury

N i C d i th Fi t


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Nursing Care during the First

(dilating) Stage of Labor(Beginning of labor to 10 cm dilated)

Labor support is primary role

Assessment of mom, fetus, labor status Information

Praise

Pain management (non-pharm vs. pharm)

Reassurance

Evaluation of expectations (realistic?)


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Latent Phase (0-3cm dilated) Vital signs q hr

Uterine contractions (ctx) q 30 min if not continuous

FHTs q 60 min through ctx and for 15 seconds after (morefrequently if high risk) if not continuous

Active Phase (4-7 cm dilated) Vital signs q hr

Uterine ctx q 15-30 min if not continuous

FHTs q 30 min or more frequently if not continuous

Transition (8-10 cm dilated)

Vitals signs q 30 min Uterine ctx q 15 min if not continuous

FHTs q 15 min or more frequently if not continuous

L t t Ph (0 3 dil t d)


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Latent Phase (0-3cm dilated)

Anticipatory guidance Teaching (brief) if needed

Tour of unit/orientation if needed

Encourage ambulation/rocking (aids in fetaldescent and ctx pattern)

Clear liquids/ice chips/popsicles (vomiting not

unusual and may need c/s later so limit fluids)

Reinforce relaxation techniques/breathing

techniques

VE to assess labor status as needed

Active Phase (4 7cm dilated)


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Active Phase (4-7cm dilated)

More frequent VEs to assess dilation, effacement, station Bloody show may begin/increase

Need to void/may need str. cath if have epidural

IV (LR) usually begun to provide fluids and as an access

for meds, general anesthesia if emergency, volume prior toepidural, and serum blood sent for?

ROM usually occurs (natural or artificial/amniotomy)-

AROM 5 minute spotlight

Note time, FHR, color, odor-Why? Which first? Once ROM may require frequent pad changes

Amnionitis risk increases with rupture > 24 hrs.

Discuss Friedman Curve


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Fern test appearance

A ti Ph t


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Active Phase cont.

Increased muscle tension common

Increased sounds if NCB (natural childbirth) Need for frequent position change if NCB

Personal comfort measures (ice, back support,

pad changes)

Support woman/family as needed

Specific breathing techniques may be helpful

Review signs of hyperventilation (Olds, 2012, p. 611)

Explanation of procedures

Initiation of anesthesia/analgesia may occur

Documentation of all assessments, interventions

and responses of mom and fetus per FM

Transition Phase (8-10 cm dilated)


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Pt center of focus turns inward

Short, clear directions best

Stay close, even if mom irritable/asks to be left alone May be acutely uncomfortable with touch, but request

sporatically

Acutely aware of uterine ctx

May appear to be sleeping between ctx. Dry lips common-ointment offered

Nurse can provide ice chips for dry mouth

Diaphoresis common

Quiet room environment

Reassurance is needed

Passage of stool common

Rectal pressure and/or increase in bloody show may promptexam/ma be 10 cm

Transition Phase (8-10 cm dilated)


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Pt center of focus turns inward

Short, clear directions best

Stay close, even if mom irritable/asks to be left alone May be acutely uncomfortable with touch, but request

sporatically

Acutely aware of uterine ctx

May appear to be sleeping between ctx. Dry lips common-ointment offered

Nurse can provide ice chips for dry mouth if appropriate

Diaphoresis common-offer cool washcloth

Quiet room environment, may want to limit visitors

Reassurance is needed

Passage of stool common

Rectal pressure and/or increase in bloody show may promptexam/ma be 10 cm and read to ush

Second (pushing) Stage of Labor


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Second (pushing) Stage of Labor10 cm dilated to delivery of NBN

Non-coached pushing may be as effective as coached

Begins to push-nurse/SO* may count, support legs

Palpate for full bladder as needed (may need straight cath.)

Feels hot Working hard

Focus of pushing with ctx usually helps pt. cope if NCB

Various positions may be used e.g. squat bar

Nurse dons protective clothing

Sets up room and NBN equipment (warmer, blankets,

resuscitative equipment)-anticipating impending delivery

*(SO=significant other)

S d t f l b ti d


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Second stage of labor continued

Perineum cleansed (clean to dirty)

Calm reassurance as NBN is born When head is out encourage mom to pant while

neck palpated for cord and nose and mouth aresuctioned

McRoberts manuever may be necessary ifshoulder stuck

Father may cut cord that is double clamped

Nurse has warm blankets to dry and stimulate

NBN on moms abdomen before assessing oneminute Apgar

Application of cord clamp with alarm by nurse,assessing for 2 arteries and 1 vein


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Third Stage of Labor

Circulate as needed to provide care to

mom and newborn-think multitask! Prepare pitocin 20units/per liter of IV fluid

to add to IV bag once placenta delivered to

facilitate involution/minimize bleeding

Reason to keep the uterus well


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Reason to keep the uterus well-

contracted after the placenta is

delivered

Needs in the 3rd stage of labor


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Needs in the 3 stage of labor

Cramping may occur and mom may be asked

to push to deliver the placenta As placenta detaches, fundus rises in abdomen

and cord extends from the vagina-may be

accompanied by a gush of blood Generally one push by mom delivers placenta-

once out, manual massage by delivering HCP,

pit per IV wide open (at least one liter-moreIVs with 20 units pit if high risk for pp

hemorrhage)

4th Stage of Labor


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4 Stage of Labor

Once placenta out, recovery period (generally 60-90 minutes)

begins

Cramping pain may be an issue for multips, while pitocin

infusing and while breastfeeding-Ibuprofen often effective

Head to toe assess q 15 min or more X 5 including vs, airway,

pain level, emotions, fundus (midline/firm or boggy/relation to

umbilicus), lochia amount, pain level, ability to move legs if

regional anesthesia

Facilitate bonding, breastfeeding, comfort, teach, newborn care

as needed

When should mom be allowed to eat?

Generally visitors/noise/excitementcontrol as needed to

promote health of mom and NBN

When should mom be transferred to postpartum? What

criteria?


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The optimal outcome!

Wh th t i t


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When the outcome is not as

planned-IUFD-5 minute

spotlight

the abcs of l&d and nursing care (1)

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