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Module C- Birth Process
Labor – What causes It ?
• The exact cause is unknown- Theories
• 1. Hormonal Influence – Progesterone/
Estrogen, Oxytocin
• 2. Uterine Stretch Theory
• 3. Fetal Endocrine Control Theory
• 4. Prostaglandin Theory
The Fetus as the Passenger
• The passage of fetus
via birth canal is
influenced by
• 1. Size of head,
shoulders & hips
• 2.Presentation
• 3.Position
Fetus as the passenger
• Head – because of its
size, rigidity &
characteristics, it is of
major obstetrical interest
• Cranial Bones: Frontal,
Parietal,
Occipital,Temporal etc
• Bones are united by
membranous sutures
:Sagittal, Frontal,
Coronal, Lamboid
• These sutures intersect to
form Fontanels: Anterior
and Posterior
Fontanels
• Sutures intersect to
form fontanels
• Anterior – found @
intersection of 2
parietal & frontal bone
• Diamond shape
• Larger of two
• Closes at 18 months
Posterior Fontanelle
• @ the junction of 2
parietal & occipital
bones
• Triangle in shape
• Smaller of the two
• Closes from birth to
12 weeks
• * Dehydration vs
Intercranial pressure*
Measurements of Interest!
• *Transverse Diameter of fetal head – Biparietal= 9.25cm
• Maternal Pelvic Measurements:
• Diagonal Conjungate DC > 11.5 – Actual diameter of
inlet. Sacral promontory & lower margin of symphysis
pubis
• True conjugate or conjugate vera (CV)- Estimate DC 1.5-2 cm. Smallest diameter of inlet. Distance between
posterior aspect of symphysis pubis & sacral promontory
• Tuberischii (Biischial) Diameter >8 OK. Actual transverse
diameter of outlet. Taken from ischial tuberosities.
Molding ?
• What molds? Due to
the fact that the
cranial bones are not
united, but are
separated by sutures
& fontanells, this aids
in the ability to
overlap & MOLD to fit
the pelvis
Presentation
• -Is that part of the
fetus that first enters
the pelvis and lies
over the inlet
• -It may be head, face,
breech or shoulder
• Presenting Part is
that part of the fetus
that lies closest to the
internal os of the
cervix
Presentation
• Three main presentations are Cephalic,
Breech, and Shoulder
• Cephalic ---------Occiput – O – Vertex 96%
•
Chin/Mentum- M- Face
• Breech ---------- Sacrum- S - Breech 3%
• Shoulder -------Scapula- Transverse Lie
= C/S 1%
Terms:
• Attitude – Relationship of fetal body parts
to each other – Flexion vs Extension
• Position- the relationship or point of
direction on the PP to one of the 4
quadrants of the mothers pelvis: ? LOA,
ROA, LOP, ROP, RSA, RSP, etc?
• Lie- The relationship of long axis of fetus
to long axis of mother- 2 choices:
Longitudinal Lie vs Transverse Lie
Factors that Facilitate the Labor
Process
•
•
•
•
•
Presenting Part
Attitude
Presentation
Position
Lie
Assessing / Evaluating the
progress of Labor
• Ischial Spines
• STATION
• Engagement or
Engaged
• *Previous
measurements
Station : Ischial spines & Fetus
Biparietal
• Head above
•
Spines
•
• Head @ IS
• Head below
• Ischial Sp
•
-3
-2
-1cm
0 Station
+1
+2
+3 cm
Labor
• Refers to the
series of
processes by
which the
products of
conception are
expelled by the
mother
Premonitory Signs of Labor
• Show- Mucus + Blood =
Show. The pressure on
cervix causes small
capillaries to rupture
• Lightening – S/S, Who has
it and when?
• ROM- What MUST I
assess and why
Are our patients really in Labor?
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Gravida
Para
Length of previous labor
? Lightening
Show- Amount, Color, Odor
ROM- (AROM, SROM ,
PROM), FHR, TIME, Color,
Odor, Gush
Contractions-Frequency,
Duration, Intensity, Felt where?
Dilatation
Effacement
Station
Has the patient’s water broken??
• The fluid can be
viewed
microscopically –
Look for Ferning
• You can use litmus
paper to see pH
changes. Amniotic
fluid is alkaline
• Blue means Baby
True verses False Labor
• ContractionsRegular,Frequency,
Duration, Quality all
increase in time &
duration
• Activity – Increase
discomfort
• Felt where?
• GI- Upset
• BOW – May rupture
• Show – None to some
• Changes In Cervix - Yes
•
• Irregular, short duration
• Relieved by walking
•
•
•
•
•
Only in abdomen
No GI upset
Intact
No show * Except*
No cervical change
Uterine contractions
• Braxton Hicks
• Pain vs Contractions
• 3 methods of assessing
Contractions
• Each contractions has 3
phases – Increment, Acme
(Peak), decrement
• Duration 45-90 sec.
• Primary powers/forces
• Frequency – Varies
• 50-60 mm Hg of pressure
(IUPC)
• External – Mild +1, Moderate
+2, Strong +3
Cervical assessment during the
labor process
• Effacement of Cervixmeans the shortening &
thinning of the cervical
canal.
• Expressed in terms or %
• The 2-3cm in length and
1 cm thick Cx will be
taken up into the lower
uterine segment
• Primigravida- 80-100%
• Multigravida – 50-80% on
admission
Effacement
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Expressed in terms or %
Less than 50% = Thick Cervix
60%
= Fairly thick
70-80%
= Fairly thin
80-90%
= Thin
90-99%
= Paper Thin
100%
= Completely Effaced
Dilatation of the Cervix
• The enlargement of the
cervical os from a few mm in
size to a size large enough for
fetus to pass. When the cx can
not be felt = 10 cm. (FT-10)
• Involuntary
• Caused by 1. Drawing up of
musculofascial components of
cx with contractions (good
ones) 2. Pressure on ex by
BOW & PP
• Should I ever NOT do an
exam?
• Do students do vaginal
exams?
Duration of Labor – How long is too
long??
• The length depends on
many factors:
• 1. Size of baby
• 2.Size of pelvis
• 3.Presentation
• 4.Position
• 5.Anesthesis &
medications
• 6.Relaxation ability
• 7.Gravida & Para
• *Average – 13-14
Primigravida and 8 hours
in Multigravida
Four Stages of Labor
• 1st Stage- Dilating
Phase
• 2nd StageDescent/Expulsion
Phase
• 3rd Stage- Placental
Phase
• 4th Stage – Recovery
Phase
FIRST STAGE OF LABOR
• 1st TRUE LABOR
CONTRACTION TO
COMPLETE
DILATION OF
CERVIX
• LATENT – FT- 4 cm
• ACTIVE – 5- 10 cm
• WHAT IS
TRANSITION?!!!!!!
SECOND STAGE OF LABOR
• CERVIX 10 CMDELIVERY OF BABY
• ARE DRUGS GIVEN
NOW?
• ANESTHESIA
• LENGTH – FEW
MINUTES – HOURS
• WHAT AFFECTS THE
LENGTH HERE?
• WHAT DO THE NURSES
DO DURING THIS
STAGE?
3RD STAGE OF LABOR
• Placental Phase
• From the delivery of baby
to the delivery of placenta
• Signs that placenta has
separated
• Length – minutes usually
• What drugs are given
here?
• What are the nurses
responsibilities during this
phase?
• Family interaction
4th STAGE OF LABOR
• Recovery Phase
• From delivery of placenta
to the first few hours
postpartum
• What drugs are given
here?
• What are the nursing
responsibilities? Assess
fundus, lochia, vital signs
• Possible complications:
Hemorrhage, urinary
retention, hypotension,
s/e from anesthesia/drugs
Maternal Adaptation to Labor
• Cardiovascular Volume
• Blood Pressure
• Respiratory changes
• WBC’s
INDUCTION OF LABOR
Induction – Artificially bringing on of
Labor after a period of viability
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Criteria
Methods of induction
Special nursing interventions
Complications
Contraindications
Uses for Oxytocin
Criteria for doing an Induction
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PROM
PIH
Hemolytic Disease
Post maturity
Diabetes
Convenience
Other
• Indications:
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–
–
PIH
SROM at or near term without onset of labor
Chorioanmionitis
Maternal medical conditions that worsen with
continuation of pregnancy
Conditions in which the intrauterine environment
is hostile to fetal well-being
Abruptio placenta
Fetal death
History of rapid labors
Living a long distance from the hospital
Methods of Inductions
• Long ago- Castor oil
and SS enema
• Rupture BOW
• Oxytocin by IV
administration
• Advantages vs
Disadvantages
• Complications
Mechanical Methods
• Placing moisture absorbing inserts into
the cervix.
– Dilapan – synthetic material
– Lamicel – synthetic sponge containing
MgSO4
– Laminaria tents – sterile, cone-shaped
preparations of dried seaweed
Special Nursing Interventions With
Inductions
• Observe contractions
– No closer than q 2
min. and no longer
than 90 seconds. If so
Stop Pitocin! (Or
decrease rate)
• If any sign of fetal
distress – Stop
Pitocin, Turn patient
and start O2
Complications
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1. Uterine tetany –
2. Fetal hypoxia
3. Ruptured uterus –
4. Fetal Anoxia
5. Maternal hemorrhage
• Contraindications:
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Complete placenta previa
Abnormal presentations
Fetal part above the pelvic inlet
Active genital herpes infection
Previous surgery in the upper uterus
• Classical C/S
– One or more low-transverse C/S with caution
– Over-distended uterus
– Severe maternal conditions (heart disease or
severe hypertension)
– Non-reassuring FHR pattern
Contraindicated uses
• 1. Normal labor
• 2. CPD
• 3. Overdistended
uterus
• 4.Fetal distress- What
types would you see?
• 5. Multiparity –
Greater than 4
Cervical Ripening
METHODS
• Prostaglandins - E2 (PGE2)
– Prepidil Gel – 0.5 mg intracervically
Repeat up to three times in 24 hours at 6 hr.
intervals.
May begin Oxytocin 6 hr after last dose.
– Cervidil vaginal insert – 10 mg in a time released
vaginal insert.
Rate of release is 0.3 mg/hr.
Remove at onset of active labor or 12 hr. after
administration.
May begin Oxytocin 30 min. after last dose.
Induction Protocol
• Patient in lateral position
• Continuous monitoring of FHR and
contractions.
• Record VS, FHR and UC for 15-20
minutes before Oxytocin started.
• Maternal VS q 15min while increasing
dose and q30 min once dose is stable.
• Temperature q4h unless membranes
ruptured.
• Main IV fluids of LR at 125 cc/hr.
• Mix Pitocin 10 Units in 1000cc D5W
• Piggyback on IV pump at closest port to
insertion site.
• Start at 2 mUnits/min and increase by
2mUnits q15 minutes until adequate labor
pattern is established.
• IV infusion rate should be maintained so
that contractions:
– Do not exceed a frequency of 5 in a 10 minute
period
– Montevideo units are 150-250
Montevideo Units
Average Intensity of contraction
X Number of contractions in 10 minutes
Montevideo Units
Example:
50 mmHg pressure
X 4 contractions
200 MVU
• Signs of Hypertonic Uterine Activity:
– Cont. duration > 90 seconds
– Cont. less than 2 min apart or less than 60
seconds between contraction.
– Uterine Resting tone > 20 mm Hg pressure
with IUPC
– Peak pressure > 90 mm Hg pressure with
IUPC
– MVU > 250
– FHR with late decelerations
WHAT TO DO!
• Nursing Care:
– Reduce or stop the oxytocin infusion
– Increase the rate of the primary nonadditive
infusion
– Keep the laboring woman in a lateral position
– Give oxygen by face mask at 8-10 L/min
– Notify the physician
Uses for Oxytocin
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Induction
Stimulation
Stress test (OCT)
Milk letdown
* Dosage
* Rate
*Bishop score
2 types of Uterine Dysfunction
• Hypotonic
• Tone less than 50mm
causing poor contractions
and little cervical change
• Tx: Rupture BOW /
Oxytocin Adm.
• Causes: CPD,
Malposition, uterine atony
from long labor
• Complications:
Exhaustion, dehydration,
Intrapartal infection
• Hypertonic
• Tone greater than 50mm
* Uterus in state of tetany,
both upper & lower contr.
• Tx: Stop Pitocin,
Tocolytics ie Brethine,
Ritodrine, MgSO4
• Causes: Pitocin
overstimulation,
spontaneous labor
• Complications: Uterine
rupture, Fetal hypoxia,
excessive pain
NORMAL LABOR
• SLOW
• LATENT
•
•
FAST
SLOW
ACTIVE
NEAR
COMPLETE
DELIVERY
• FORCES
>
• PASSANGER <
•
PASSANGER
PASSAGE
Operative Obstetrics
• Lacerations -1st,2nd,
3rd Degree
• Episiotomy – Midline*,
Mediolateral (rarely
done)
• Forceps (Low forceps
/ outlet )/ Vacuum
extraction
• C- Section
Episiotomy- Incision of perineum to
facilitate delivery
• Midline- Advantage- Easier to repair, less
uncomfortable. Disadvantage.- Greater chance
of tearing into the rectum
• Mediolateral – Adv. Less chance of tear, Disadv.
– Harder to repair & > pain
• Reasons to do an Episiotomy• 1.Easier to repair than tear/laceration
• 2.Direction can be controlled
• 3.Less pounding of fetus/Overstretching less
• 4.Shortens 2nd stage of Labor
• What is ironing the perineum??
Indications for C/S
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CPD
Previous C/Section ?
PIH
Abruptio Placenta /
Placenta Previa
Fetal distress
Diabetes
Herpes simplex II
Infertility
Others
Types of C/S
• 1. Lower segment
section
• 2. Classical
• 3. Caesarian
Hysterectomy
• *Preparing for C/S
• *Post- op care &
special considerations
VBAC
• Criteria
• Common
complications
• What are the risks?
C/S- Why?
• Variation in Pelvis
• 1.CPD – Treatment
• 2.Oversize baby – Complications and
common causes
• 3.Shoulder Dystocia – What’s done here?
• 4. Hydrocephalus
Fetal Monitoring
Clinical Prep : Fetal Monitoring
• Random Auscultation vs
Continuous Fetal
Monitoring
• Which patients do we
monitor?
• EFM (Electronic Fetal
Monitoring) is a useful
tool in evaluating fetal
response to labor.
• Fetal O2 supply must be
maintained during labor
Fetal Response to the Intrapartum
Period
• Fetal O2 supply can be reduced by:
• 1. Decreased blood flow thru maternal
vessels as a result of maternal
hyper/hypotension
• 2.Maternal hemorrhage or anemia
• 3. Fetal circulation: Cord occulsion,
placenta separation, Old placenta
• 4. Fetal condition: IUGR
• 5. Contractions too close or too long
Monitoring Options
• External –
Tocotransducer &
ultrasound
• Combination – Toco &
Fetal Spiral Electrode
(FSE)*
• Internal – FSE & IUPC
(Internal uterine pressure
catheter)*
• *Membranes must be
ruptured, best in
detecting ST variability
Terms you need to know!
• Baseline FHR- FHR
between contractions &
periodic changes
• Tachycardia- Baseline
above 160 BPM
• Bradycardia- FHR below
110 BPM
• Variability – Fluctuation,
Beat to beat changes.
Normal irregularity of
cardiac rhythm. STV/LTV
• Examples of periodic
changes:
• Accelerationsacceleration with FM is a
reassuring pattern
• Decelerations
• 1. Early
• 2. Late
• 3. Variables
• FHT – 120-160
– Could be as low as 110 and still be normal.
– Bradycardia - <100 BPM
– Tachycardia – >180 BPM
• Variability:
– Short-term variability (beat-to-beat) – 5-10
BPM. Only accurate on a FSE.
– Long-term variability (reactivity) – periodic
accelerations that are >15 BPM lasting >15
seconds in duration
Decelerations
DECELERATIONS
• Look at three things
• 1.Shape of the decelerations- Uniform vs
variable shape
• 2. Time relationship to contractions- Does
the deceleration occur with the C, after the
C or does it VARY?
• 3. Range of decelerations – Does the
deceleration go down to 60 / 100 / or 120
etc
Early Decelerations
• Occur with contractions and are
usually caused by head compression.
– Start with the contraction (early) Mirror
image
– Peak with the contraction
– Return to baseline as contraction goes
away –
– Usual range is 100-140
– Has uniform shape
Nursing Interventions for early
Decelerations
• NONE
• Usually benign
• No Treatment except
to continue to assess
and monitor
Variable Decelerations
• Occur with or without contractions and
are caused by cord compression.
– Look like a U, V or W (variable shape)
– Rapid onset with rapid return to baseline.
– May drop below 100 BPM. Vary in rate ie
60-100
– Can progress to terminal bradycardia.
Nursing Interventions for Variable
Decelerations
• Change maternal
position-- R-L, L-R
• Change it again if not
better (Knee chest if
severe)
• Amnioinfusion
• Administer O2
(Makes nurses feel
better)
Late Decelerations
• Occur as a result of utero-placental
insufficiency (decreased tissue perfusion to
the fetus).
– Start at the peak of the contraction. (Late)
– Lowest point at the end of the contraction.
Rarely goes below 110
– Slow return to baseline after end of
contraction.
– May also see a loss of variability.
– Could be associated with maternal
hypotension as a result of regional
anesthesia.
Causes for Late Declerations
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Occurs with
1. Maternal supine hypotension
2. Excessive Oxytocin
3.PIH
4.Post mature syndrome
5.Amnionitis/SGA
6. Anesthesia
7.Cardiac disease
Nursing Interventions for Lates
• Turn patient if cause is
supine hypotension
• Start O2
• Decrease uterine activity
(Stop pitocin, administer
Brethine)
• Correct Hypotension
• Lates should not occur
longer than 30 minutes
without seeing
improvement
Fetal Monitoring & Decelerations
• Decelerations –
Which ones are OK &
which ones are not?
• Is it good to be Early
for work? OK
• Is it OK to be Late for
work? NO
• What if I do both?
Then it may or my not
be OK. Variable
Complications of the Intrapartum
Period
• RUPTURED UTERUS
Who is at Risk?
• Previous C/S
– Classical vs. low segment
• Induction
– Pitocin, Cervadil or Cytotec
• Long, strong labor
• High Parity
– Thin uterine wall
• Blunt abdominal trauma
TYPES OF UTERINE RUPTURE
• COMPLETE – a direct break between
the uterus and peritoneal cavity.
• INCOMPLETE – rupture into the
covering of the uterus or into broad
ligaments but not into the peritoneal
cavity.
• DEHISCENCE – partial separation of
an old uterine scar. Little or no bleeding
may occur.
Signs and Symptoms
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Sudden severe abdominal pain / tenderness
Absent FHT
No palpable contractions felt
Vaginal bleeding
Abdominal distension and rigidity
Shock
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–
Hypotension
Elevated pulse rate
Elevated respiratory rate
Pale, clammy skin
anxiety
Management
• Stabilize the Mom
and Fetus if
possible
– Increase IV fluids
– O2 administration
– T & C, and administer
blood (O-)
• Emergency C/S
• Hysterectomy if
complete rupture
• Antibiotics
INVERSION OF THE UTERUS
• Cause:
– Pulling on umbilical cord prior to release
from uterine wall
– Pressure on uterine fundus while relaxed
– Abnormally adherent placenta
– Congenital weakness of the uterine wall
– Fundal placental implantation
• Signs and Symptoms:
– Fundus cannot be felt or is depressed
– Interior of uterus may be seen thru cervix or
protruding out of the vagina
– Massive vaginal bleeding
– Shock
•
•
•
•
Hypotension
Decreased PR and RR
Pale, clammy skin
Restlessness
– Severe pelvic pain
Treatment:
Dr. will attempt to replace the uterus
through the vagina to a normal position,
or Laparotomy replacement is attempted
Hysterectomy may be required.
Two IV lines with large bore needles
Fluids and blood replacement
Oxytocin to control blood loss after
repositioning.
Observe for shock and treat accordingly.
Keep UOP >30 ml/hr.
NPO until stable
Preterm Labor
• Labor occurring after
28th week but, before
the 37th week gestation
• Infant mortality and
morbidity increase the
earlier the delivery
• 2nd leading cause of
infant mortality
– Prematurity and low
birth weight
• Cause:
– Not fully known
• Risk Factors:
– Maternal
•
•
•
•
CV or Renal disease
Diabetes
PIH
Uterine or cervical
anomalies
• Cervical
Incompetence
• UTI
• Anemia
(See chart on page
750)
– Fetal
• Multiple
pregnancy
• Hydramnios
• Fetal Infection
– Placenta
• Previa
• Abruptio
• PROM
Assessment Data:
EDC
Course of pregnancy (problems)
Fetal condition
Maternal condition
Contractions
Greater than 6/hr with cervical changes
Cervical changes
Length < 25mm (allows greater entrance of
microorganisms that weaken membranes and cause
PROM
– Infections
• GBS
• UTI
– fFN test (fetal fibronectin)
• should be – after 22 weeks gestation. Normal 23 weeks prior to onset of labor.
– Salivary estriol
• Elevates about 5 weeks before onset of labor.
– PROM in previous pregnancy
– CBC
• Especially Hgb and Hct
– L/S ratio
• For fetal maturity
PTL
• Treatment:
– Prevention
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•
•
•
•
Early prenatal care
Assessment of those at increased risk
Promote adequate nutrition
Teaching early signs of PTL
Encourage patient to seek care if symptoms
occur even if they seem mild
• Treatment of infections ASAP with appropriate
antibiotics
PTL
– Will not stop labor
if:
• Active labor with
dilation >4 cm
• Severe PIH
• Fetal complications
(Rh or gross
anomalies)
• RBOW with infection
• Hemorrhage
• Fetal demise
PTL Care
– Medical Care:
• Bed rest
• Monitor contractions
and FHT
• Position on left side
• IV fluids
• Limit vaginal exams
• Assess and treat
infections
UTI
+GBS
• Assess and treat
anemia
• No sexual stimulation
• Emotional support
Drug Management
– Drug management:
• MgSO4 – 0.5 – 3 Gm IV
usual dose
– Usually first choice
– Acts as CNS and
smooth muscle
relaxant
– Always have
Calcium gluconate
on hand as antidote
Give 5-10 mEq
(5-10 ml) IV over
a 3 min. period
• Brethine (Terbutaline)
– Asthma drug
– Beta-adrenergic
agonist that causes
relaxation of the
smooth muscles
– 0.25 mg SQ and 5 mg
po then 2.5-5 mg po
q2-4 hours
– Must be taken around
the clock!
– Side Effects
» Fetal and maternal
tachycardia
» Nervousness
» Pulmonary edema
» Increased serum
glucose
» Decreased serum
potassium
Drug Therapy
– Ritodrine (Yutopar) –
• Beta-adrenergic agonist and causes smooth
muscle relaxation.
• 10 mg po q2h X 24 hr then 10-20 mg q4-6 hr
• May also be give IV on pump at 0.1 – 0.35 mg /
minute (Mix 150 mg in 500 ml D5W = 0.3 mg/ml)
• Side Effects:
– Tachycardia
– Palpitations
– Pulmonary edema
Drugs affecting the Fetus
• Glucocorticoids
(Betamethasone
or Celestone)
– Used to stimulate
fetal lung
production of
surfactant
– 12 mg IM repeated
in 12 to 24 hours
– Works in 1 day
– Lasts for 7 days
– Must repeat
weekly if
undelivered and
still at risk for PTL
Home Treatment
– Home Treatment
• Bed rest on left side –
with BRP
– Increases placental
blood flow
– Decreases pressure
on cervix
– Complications:
» CV deconditioning
» Muscle and Ca
loss
» Weight loss
» Depression
» Anxiety
What’s OK and Not OK
• Brethine (or
Yutopar) po
– Be sure patient
knows how to
check pulse rate
– Teach patient
about chart to
ensure pills taken
as directed
– Make sure she
knows to take
around the clock
(set alarm clock)
• No sexual
stimulation
• Increased fluids
– Oral fluids – juice, milk, gelatin, etc
– IV fluids – be careful if pts. on Brethine will be at risk
for pulmonary edema
– Encourage pt. to drink 1-2 8oz. glasses of water if
begin to have contractions
– Adequate hydration decreases the release of antidiuretic hormone and possibly oxytocin from the
posterior pituitary gland and increases uterine blood
flow thereby stabilizing decidual lysosomes so
certain acids (arachidonic) will not be freed to be
converted into prostaglandins.
– Hydration also decreases the risk of UTI
What else?
• Report contractions >6/hr
• Delegate home responsibilities to others
• Home assessment
– Stairs
– Telephone access
– Change in home routines
– Change in expectations
• Activities to do while on bed rest
• Games to play with other children
– Emotional Support
– Delivery
• Vaginal or C/S depends on individual
• Increased risk for prolapsed cord
Prolapsed Cord
• Occult – cannot be seen or felt
• Apparent – cord can be seen at the
vaginal opening or felt on vaginal exam
Occult Prolapse- Hidden
What would you feel and hear?
What would you see and hear?
Which patient’s can have this?
• Most commonly occurs:
–
–
–
–
–
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–
–
At the time of rupture of membranes
If the presenting part is not engaged
Abnormal presentation – breech, transverse lie,
Small fetus
Long cord
Low lying placenta
Hydramnios
Multiple births
• Signs and Symptoms:
– Variable decelerations (especially at time
of ROM)
– Fetal tachycardia progressing to
bradycardia
• Treatment:
– Change position to opposite side
– Knee chest or trendelenburg position
– Vaginal exam and place pressure on
presenting part
– If cord protruding from vagina – cover with
wet gauze soaked in sterile saline
– Prepare for immediate C/S
– NEVER try to replace the cord
Uterine Dystocia
Dystocia- Long or difficult laborCauses
1. Dysfunctional Labor – ineffective
contractions or ineffective bearing down.
2. Alterations in pelvic structure
3. Fetal causes –
1.
2.
3.
4.
abnormal presentation or position
anomalies
size
number
4. Maternal position
5. Psychological responses to labor
DYSFUNCTIONAL LABOR
• Usually occurs before
4 cm dilatation
• Cause unknown
• May be related to fear
and tension
• Signs and Symptoms:
– Pain out of proportion to intensity of
contractions
– Pain out of proportion to effectiveness of
contractions – poor effacement and
dilatation
– Contractions increase in frequency
– Contractions uncoordinated
– Uterus remains contracted between
contractions (poor resting tone)
• Results:
– Maternal loss of control and exhaustion
– Fetal asphyxia with meconium aspiration
• Treatment:
– Analgesia to allow rest (if no ROM or CPD)
– Discontinue Pitocin if being induced
– Sleeping pill if late in afternoon to allow
overnight rest
– When contractions resume may be normal
SECONDARY OR HYPOTONIC
UTERINE DYSFUNCTION
• Most common type of dysfunction
• Initially makes normal progress into the
active stage of labor and then contractions
become weak and ineffective or stops
altogether.
• Cause:
–
–
–
–
Unknown
CPD
Malposition
Overdistension of the uterus
• Results:
– Infection – maternal and
fetal
– Exhaustion
– Psychological trauma
– Fetal and neonatal death
• Treatment:
– Rule out CPD
– Oxytocic stimulation or
augmentation
– Amniotomy (AROM)
INADEQUATE VOLUNTARY
EXPULSIVE FORCES
• Compromised bearing down efforts
prolong the second stage
• Cause:
– Heavy sedation
– Conduction anesthesia (epidural or spinal)
– Exhaustion due to:
•
•
•
•
long labor
lack of sleep
hunger
positioning
• Signs and Symptoms:
– No voluntary urge to push or bear down
– Inadequate/ineffective pushing
• Results:
– Spontaneous vaginal birth prevented
– Fetal asphyxia
– Need for use of forceps or vacuum
extractor
• Treatment:
– Coach mother in bearing down efforts
– Position mother in favorable position for
pushing
– Low forcep or vacuum assisted birth
– Episiotomy
– C/S birth only if non-reassuring fetal status
ALTERATIONS IN PELVIC
STRUCTURE
PELVIC DYSTOCIA
• Occurs whenever there are contractures of
the pelvic diameters that reduce the capacity
of the bony pelvis.
• Cause:
–
–
–
–
–
Congenital abnormalities
Malnutrition
Neoplasms
Lower spinal disorders
Immature pelvis in adolescent mothers
• Signs and Symptoms:
– Failure to progress Arrested descent
– Weak uterine contractions during the first
stage of labor
– Cervical edema
• Results:
– Increased perinatal morbidity and mortality
– Extensive perineal lacerations
• Treatment:
– C/S
– Vacuum assisted vaginal birth (if
completely dialated)
SOFT TISSUE DYSTOCIA
• Results from obstruction of the birth
canal by an anatomic abnormality other
than the bony pelvis
• Cause:
– Placenta Previa
– Uterine fibroids
– Ovarian tumors
– Full bladder or rectum
– Cervical edema
Fetal causes of Dystocia
ANOMALIES
•
•
•
•
Gross ascites
Abnormal tumors
Myelomeningocele
Hydrocephalus
CEPHALOPELVIC
DISPROPORTION
• CPD
• Also called Fetopelvic Disproportion
(FPD)
• Related to excessive fetal size >4000
gm
• Cause:
– Diabetes
– Large parents
– Multiparity
Malposition
• Most common is persistent occipitoposterior
• Interferes with the fetal ability to exit
the pelvis
Malpresentation
• Most common is breech
– 3-4% of all deliveries
– 25% of preterm births
• Transverse lie
• Face and brow presentations also a
problem
MUTIFETAL PREGNANCY
• In only half of twin pregnancies do both
fetuses present in the vertex position.
• Second baby may turn to another
position during the delivery of the first
baby.
• Usually have to attempt an intrapartal
version.
• May deliver first baby vaginally and
second baby by C/S.
POSITION OF THE MOTHER
• The incidence of dystocia is increased in
women confined to the recumbent or
lithotomy position.
• Increases the need for:
– Augmentation of labor
– Forceps or vacuum extractors
– C/S
• Knee-chest positon
– Helpful for rotation of the fetus from posterior to
anterior position
• Sitting and squatting
– Facilitates fetal descent during pushing
PSYCHOLOGICAL RESPONSE
• Hormones released in response to
stress can also cause dystocia.
– Pain
– Absence of support person
– Lack of knowledge
NURSING DIAGNOSES FOR
DYSTOCIA
• ANXIETY R/T
– Slowed labor progress
– Perceived threat to well-being of self or
fetus
• PAIN R/T
– Dystocia
– Obstetric procedures
• RISK FOR FETAL INJURY R/T
– Obstetrical procedures
– Prolonged labor process
• RISK FOR MATERNAL INJURY R/T
– Interventions implemented for dystocia
• RISK FOR INFECTION R/T
– Premature rupture of membranes
– Operative procedures
– Prolonged labor
• FATIGUE R/T
– Prolonged labor
– Length of pushing
• RISK FOR ALTERED PARENT-INFANT
ATTACHMENT R/T
– Unplanned cesarean birth
– Increased pain
• INEFFECTIVE INDIVIDUAL COPING R/T
– Lack of knowledge regarding measures used to
enhance labor and facilitate birth
– Pain
– Fatigue
– Lack of support system
• SITUATIONAL LOW SELF-ESTEEM R/T
– Inability to labor and give birth as expected
The Nurses contribution to Pain
relief for the labor patient
• Expectations
• Why is controlling pain during labor
important?
• Pain tolerance vs pain threshold
• Causes of pain during labor
• Descriptions of pain during labor
• Factors that cause greater discomfort
• How can the nurse help/
Anesthesia/analgesia
• Analgesia – Pain
relief or less pain
sensation
• Anesthesia – Loss of
sedation
• When should patients
receive anesthesia or
analgesia?
Assessment Requirements
regardless of type of Anesthesia
• Neuro – Level of consciousness
• CV – B/P, P, with observation of color/temp
and IV patency
• Respiratory- Respiratory rate & rhythm
with lung sound, ? Use of accessory
muscles
• GI – Nausea, vomitting
• GU – Urinary output
Drugs in L&D
•
•
•
•
•
•
•
•
Phase
Drugs
Progress
Latent
Stadol /Demerol
1-3cm
Active
Stadol / Demerol* 3-9 cm
2nd stage
Narcan / Pitocin Complete
3rd stage
Pitocin
Birth---*Avoid giving Narcotics late in labor
In case of C/S Administer Bictra/
Choice of anesthesia is best discussed during
pregnancy rather than labor
Types of anesthesia
• IV - Sodium Pentothal – Used for emergency
only – causes Fetal depression and maternal
laryngospasms
• Regional
• 1. Local infiltration
• 2. Pudendal Block
• 3. Caudal
• 4.Lumbar Epidural*
• 5.Saddle/spinal block
Types of Anesthesia
• Assess for allergies to
“caine” drugs
• Local Infiltration –
repair Episiotomy or
lacerations
• Pudendal Block –
external/internal, no
affect on contractionsBlocks the perineal
area for delivery
Peridural anesthesia
• Caudal - 1st & 2nd
stage- Introduced in
peridural space @
sacral hiatus
• Lumbar “Epidural” –
1st & 2nd stageApproach from
lumbar region- Most
common
Spinal anesthesia
• Saddle block- Affects
the portion that
touches a saddle of a
horse. Enters the
subarachnoid space.
Vaginal delivery
• Spinal – Enters the
subarachnoid space.
Vaginal or C/S
• Special nursing
interventions required
Common complications
• Hypotension from
Epidural due to :
• 1.Rapid absorption of
anesthetic agents
• 2.Position (Supine
Hypotension)
• Hypotension from spinals
due to:
• 1.Peripheral vasodilation
& altering return blood
flow
• 2.Position factor
Nursing interventions
• Increase IV fluids
• Use Left pelvic tilt
• Administer Ephedrine
5-10 mg IV as
ordered by MD
• Administer O2 8-12 L
as ordered
• Assess for fetal
distress – What might
you expect to see?
Answer:
• Fetal distress ie Fetal Bradycardia or Late
decelerations
• Causes:
• 1. Rapid absorption of drug (Marcaine)
• 2.Result of hypotension (mother)
• 3.Inadequate placental perfusion for
multiple causes. Can you list some of
them?
Other complications from
anesthesia
•
•
•
•
•
Post spinal Headache
A. Occurs 24-72 hours
B. Last few days to several weeks
C. Mild--------to severe!!
D. H/A is positional- May be felt in back, neck,
head & / or shoulders
• E. Cause- Loss of cerebral spinal fluid
• Treatment – analgesics, flat in bed, BR, Rest in
prone position, increase hydration, *Epidural
blood patch
• Anaphylaxis – always possible