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Labor and Delivery Marianne F. Moore Critical Factors in Labor Passage Critical Factors in Labor Passage Passenger Critical Factors in Labor Passage Passenger Powers Critical Factors in Labor Passage Passenger Powers Psyche Critical Factors in Labor Passage Passenger Powers Psyche Position (Maternal) Critical Factors in Labor Passage Passenger Powers Psyche Position (Maternal) Placental Passage Skeletal Structures Pelvis Types Gynecoid Anthropoid Android Platypelloid Passage Skeletal Structures Pelvis Types Gynecoid Anthropoid Android Platypelloid Passage Soft Tissue Structures Cervix Cervical Scarring Vagina Obstructions “Tissue Dysplasia” Passenger Lie Passenger Lie Attitude Passenger Lie Attitude Presentation Passenger Lie Attitude Presentation Position Passenger Lie Attitude Presentation Position Station Powers Contractions Duration Frequency Intensity Powers Contractions Increment Acme Decrement Psyche Immediate Issues Fatigue Anxiety Trust in Medical Care and Self Ability to Receive and Use Support Psyche Pre-Existing Issues Motivation for the Pregnancy Self-Confidence Personal Expectations Relationship with Support Person(s) Culture and Its’ View of Childbirth Obstetric/ Family History Childbirth Education Classes Maternal Position Bedrest: Low semi-Fowler’s Necessary position with epidural placement Patient is tipped to one side to avoid vena cava syndrome Changing position from one side to other changes relationship of presenting part to maternal pelvis Maternal Position Bedrest: Side-lying or “runner’s position” Useful for rest in early labor Also a good position for sleep in advancing pregnancy Needs lots of pillows for comfort and correct positioning Maternal Position Upright Positions: Chair/Rocker Walking Stair Climbing (especially 2 at a time) Birthing Ball Squatting/Squat Bar Toilet sitting Maternal Position Positions to help back labor: Leaning over the bed All fours Pelvic rocking Leaning on the hallway bars Slow dancing Counterpressure Placenta Low-lying placenta may cause the baby to assume a transverse lie May also impede descent of the baby Cardinal Movements Engagement Cardinal Movements Engagement Descent Cardinal Movements Engagement Descent Flexion Cardinal Movements Engagement Descent Flexion Internal Rotation Cardinal Movements Engagement Descent Flexion Internal Rotation Extension Cardinal Movements Engagement Descent Flexion Internal Rotation Extension Restitution Cardinal Movements Engagement Descent Flexion Internal Rotation Extension Restitution External Rotation Cardinal Movements Engagement Descent Flexion Internal Rotation Extension Restitution External Rotation Expulsion (BIRTH!) Signs of Labor Lightening Frequent Urination Sciatic Nerve Discomfort Back Discomfort Signs of Labor Lightening Frequent Urination Sciatic Nerve Discomfort Back Discomfort Braxton-Hicks (Warm-Up) Contractions Vaginal Discharge Bloody show Nesting Signs of Labor Rupture of membranes Called PROM if before contractions start Amount of fluid can vary Assess Time of Rupture Color of fluid Clarity of fluid Fetal movement since rupture? Have contractions started? Signs of Labor What is “False Labor”? Looks/feels like labor to mother but no change in cervix Abdominal/groin pain Changing level or type of activity makes contractions go away Contractions don’t get stronger, longer or closer together (intensity, duration, frequency) Contractions do not change the dilatation or effacement of cervix Signs of Labor What is “True Labor”? Contractions that efface or dilate the cervix Contractions usually cause low back pain or suprapubic pressure (or both) Contractions are regular and rhythmic Changing type or level of activity does NOT make them go away Contractions get longer, stronger, closer together (duration, intensity, frequency) Theories About the Onset of Labor Progesterone Deprivation Theory Oxytocin Theory Fetal Endocrine Control Theory Prostaglandin Theory Physiologic changes with L & D Labor is hard physical work Physiologic changes with L & D Labor is hard physical work Increases in systolic and diastolic BP Physiologic changes with L & D Labor is hard physical work Increases in systolic and diastolic BP Increased cardiac output Physiologic changes with L & D Labor is hard physical work Increases in systolic and diastolic BP Increased cardiac output Fluid and electrolyte loss: diaphoresis hyperventilation elevated temperature Physiologic changes with L & D Peristalsis slows in most of GI tract, except lower colon Physiologic changes with L & D Peristalsis slows in most of GI tract, except lower colon Decreased absorption of solids Physiologic changes with L & D Peristalsis slows in most of GI tract, except lower colon Decreased absorption of solids Anorexia is common Physiologic changes with L & D Peristalsis slows in most of GI tract, except lower colon Decreased absorption of solids Anorexia is common Nausea and vomiting can occur during transition Fetal Response to Labor Persistent fetal heart rate changes may indicate changes in fetal wellbeing Fetal Response to Labor Persistent fetal heart rate changes may indicate changes in fetal well-being Most fetuses are well equipped for the stress of labor Fetal Response to Labor Persistent fetal heart rate changes may indicate changes in fetal well-being Most fetuses are well equipped for the stress of labor Initial assistance to the fetus is provided through the mother (position change, fluids, O2) Fetal Response to Labor Persistent fetal heart rate changes may indicate changes in fetal well-being Most fetuses are well equipped for the stress of labor Initial assistance to the fetus is provided through the mother (position change, fluids, O2) A more thorough discussion is in the section on fetal monitoring Stages of Labor Stage 1 Onset of labor to complete dilatation (10 cms) Stages of Labor Stage 1 onset of labor to complete dilatation (10cms) Stage 2 Complete dilatation to birth Stages of Labor Stage 1 onset of labor to complete dilatation (10cms) Stage 2 Complete dilatation to birth Stage 3 Birth to delivery of the placenta Stages of Labor Stage 1 onset of labor to complete dilatation (10cms) Stage 2 Complete dilatation to birth Stage 3 Birth to delivery of the placenta Stage 4 Delivery of the placenta until 1-4 hours after delivery (depends on the mother) First Stage of Labor Phases Latent, also called early Latent Phase of Labor Lasts from onset until 4 cms dilated Contractions: mild, 30-45 seconds long Regular and increasing in frequency, usually 5-10 minutes apart Work: primarily effacement Length: Primipara:8 hours, up to 24 hours Multipara: 5 hours, up to 14 hours Client is happy, talkative, outgoing First Stage of Labor Phases Latent Active Active Phase of Labor From 4 to 7 cm dilatation Contractions: moderate, 45-60 seconds From 2-5 minutes apart Work: Dilatation and descent Length: Primipara: 4.5 hours, on average Multipara: 2.4 hours, on average Client becomes introspective, serious and tense First Stage of Labor Phases Latent Active Transition Transition From 8-10 cms dilated (10 cm is complete!) Contractions: strong, last 60-90 seconds every 2-3 minutes a “break” can occur at 10 cms, for 20 minutes or so, especially if Mom is very tired Work: descent and some dilatation Length: Primiparas: 3.6 Multiparas: varies Client discouraged, irritable. “Can’t do this!” Second Stage of Labor From complete dilatation to birth Contractions last 60-90 seconds with strong intensity every 1.5-2 minutes a “break” can occur at 10 cms, for 20 minutes or so, especially if Mom is very tired Lasts 15 minutes to 2 hours (average) With epidural, can be up to 3 hours Perineum bulges, labia separate and head crowns Behaviors in Second Stage Urge to bear down is strong Pushing feels more productive to many mothers; they are eager to push Exhausted mothers may find the exertion overwhelming Burning as head crowns often causes fear of “splitting open” Pushing causes very intense sensations that can frighten unprepared mothers Pushing Techniques Directed pushing Begins when mother is completely dilated Patient takes two good breaths, then takes and holds a third breath. While holding the breath, she pulls back her knees and pushes for a count of 10 Cycle repeated X 3 Pushing Techniques Spontaneous Pushing Mother is encouraged to wait to push until the urge to bear down is overwhelming With some multips, this can occur at 8-10 cms She is then told to breathe until the urge is strong, push until she needs to breathe, and repeat until the urge is gone Urge usually strong at +1 station Pushing starts 1-2 per contraction, can get to 3-4 pushes per contraction as head descends Pushing Techniques Waiting for the urge to push referred to as “laboring down Urge to push with epidurals may not occur until long after 10 cm Studies show no advantage to directed pushing Laboring down and spontaneous pushing result in shorter pushing times and less fetal stress Episiotomy Surgical incision of the perineal body Midline cut in a straight line along the median raphe (from the vaginal orifice towards the rectum) Divides the insertions of the perineal muscles Mediolateral (usually right) Begins in the midline of the posterior fourchette (to avoid Bartholin’s gland) and extends at a 45 degree angle downwards Benefits of Episiotomy Hastens delivery if there is fetal distress May be needed if the perineum is unyielding May give more room for maneuvers with shoulder dystocia May give room for use of forceps or vacuum Risks of Episiotomy Fecal and/or urinary incontinence Pain in the area can persist for 6 months or more Increased pain with intercourse Bleeding Bruising Swelling Infection Third Stage of Labor From birth of infant to delivery of the placenta Lasts from 5-30 minutes Contraction of the uterus decreases the surface area under the placenta and causes the placenta to “buckle”; a hematoma forms and extends, pushing the placenta off the uterine wall Third Stage of Labor Signs of separation Uterus becomes globular The fundus (top of the uterus) rises Gush of dark red blood Umbilical cord lengthens (as uterus descends) Gentle traction on the cord assists in delivery and decreases bleeding Hemorrhage is primary concern Fourth Stage of Labor Lasts 1-4 hours after delivery Beginning of physiologic readjustment of the mother’s body 250-500 cc blood loss is common Causes drop in systolic and diastolic BP, tachycardia, increased pulse pressure Fourth Stage of Labor Uterus is contracted, midline and near the umbilicus Oxytocin is given after delivery of the placenta to increase uterine contraction and decrease bleeding Bladder may be hypotonic from anesthesia, analgesia, trauma Vital signs, fundal height and vaginal flow checked every 15 minutes X 5 (1st hour) Fourth Stage of Labor Baby should be given to mother for bonding and to initiate breastfeeding as soon as possible Shaking/chilling is common Ending of the physical exertion of labor Most women are hungry, thirsty and tired Nursing Care During Labor Admission assessment Date and Time of Admission Primary Care Provider: Mom and Infant EDC, Gravida / Parity Allergies Maternal Medical History Medications Taken During Pregnancy Problems with previous pregnancies Nursing Care During Labor Admission assessment (continued): Problems with this pregnancy When labor started Contraction pattern (frequency, duration, intensity) Any vaginal discharge Membranes ruptured or intact: amount/color/odor Nursing Care During Labor Admission assessment (continued) Fetal movement? Fetal heart tone assessment/reactive? Vital signs, including temperature Vaginal exam for dilatation, effacement and station Labs: MBT, infectious status, GBS? Psychological status Electronic Fetal Monitoring External Contraction Assessment: Tocodynamometer (toco for short) placed at the top of the fundus Uterus rises and moves forward during the increment, then reverses with decrement Creates typical “hills” on monitor screen/paper Appearance of the tracing depends on maternal position, weight, parity Electronic Fetal Monitoring External Fetal Assessment: Ultrasound transducer detects sound waves Prefers the loudest sound Affected by position of the fetal heart in relation to the transducer Affected by thickness of maternal abdomen Electronic Fetal Monitoring Internal Contraction Assessment Internal Uterine Pressure Catheter (IUPC) Directly measure pressure exerted by uterus in mmHg Internal Fetal Assessment Fetal scalp Electrode (FSE) Directly measure fetal heart rate Can add assessment of shortterm/beat-to-beat variability Fetal Heart Rate Monitoring Baseline A 10 beat range that describes FHR between contractions over a 10 minute time period Normally 110 bpm to 160 bpm Fetal Heart Rate Monitoring Bradycardia: Below 110 bpm Moderate bradycardia from 81-110 bpm Severe bradycardia less than 80 bpm for 2-3 minutes Causes to consider Maternal hypotension (common with epidural) Late (profound) fetal asphyxia Prolonged umbilical cord compression Fetal arrhythmia Fetal Heart Rate Monitoring Tachycardia: above 160 bpm Mild: 161-180 bpm Severe: 181 bpm or greater Fetal Heart Rate Monitoring Fetal tachycardia (continued) Causes to consider Maternal fever Dehydration Betasympathomimetic drugs (e.g. terbutaline) Early fetal hypoxia Maternal hyperthyroidism Fetal arrhythmia Fetal anemia Fetal Heart Rate Monitoring Variability Measure of the interplay of the sympathetic and parasympathetic nervous systems Assessed as a sign of fetal well-being Fetal Heart Rate Monitoring Long Term Variability Larger rhythmic fluctuations of FHR Occur 3-5 times per minute Normal range of 6-10 bpm Increases w/movement; decreases with sleep Classifications Decreased 0-5 bpm Average/ moderate 6-25 bpm Marked/ saltatory 25 bpm+ Fetal Heart Rate Monitoring Short Term Variability Difference between R wave to R wave in successive heartbeats Represents actual fluctuations from one heartbeat to the next Average 2-3 bpm Classification Present or absent Fetal Heart Rate Monitoring Sinusoidal Pattern Wavelike baseline Amplitude of 5-15 bpm Regular oscillating pattern 2-5 cycles per minute Absence of short or long term variability Associated with severe asphyxia, Rh isoimmunization, anemia, fetal-maternal hemorrhage, abruptions, or fetal acidosis Narcotics produce a pseudosinusoidal pattern Fetal Heart Rate Monitoring Accelerations Transient rises in fetal heart rate above the established baseline Non-periodic Usually movement related Two (2) 15 bpm accelerations that last for 15 seconds = reactive non-stress test Periodic Response to stress of contraction Fetal Heart Rate Monitoring Decelerations Periodic decreases in fetal heart rate from the baseline Relationship to contractions and waveform determines type of deceleration Fetal Heart Rate Monitoring Early decelerations Uniform in appearance and mirror the corresponding contraction Caused by pressure on the fetal head FHR rarely drops below 100 bpm or more than 30 bpm lower than baseline Usually occur between 4-7 cm Benign, unless the baby is not descending into the pelvis Fetal Heart Rate Monitoring Late decelerations Due to uteroplacental insufficiency Reflect decreased blood flow during contractions with decreased oxygenation Have a smooth uniform shape (saucer-like) Begin after contraction is established and nadir is at end of ctx Often coupled with decreased variability Ominous, must be treated/ provider notified Fetal Heart Rate Monitoring Variable decelerations Vary in onset, occurrence, duration, intensity and waveform There is a visually abrupt drop in FHR Thought to be due to cord compression Positional or due to decreased AFI May be non-periodic or periodic If they last >60 seconds or are less than 70 bpm, then are a cause for alarm Otherwise innocuous Fetal Heart Rate Monitoring Prolonged decelerations FHR decreases from the baseline for 2-10 minutes Can be caused by cord prolapse or maternal hypotension (with regional anesthesia) If baseline becomes tachycardic, indicates hypoxia and stress Nursing Role in Labor Accurate assessment of fetal response to labor Accurate assessment of maternal response to labor Accurate assessment of the emotional responses of the woman and her support system Nursing Role in Labor Interventions Fetal Support-correct adverse FHR changes Maternal hydration Maternal oxygenation Maternal position changes Nursing Role in Labor Maternal support: correct deficiencies Maternal nutrition and hydration Maternal oxygenation Pain coping Facilatation of the maternal support system Helping the support person to help the mother Suggestions and actual demonstration of helpful behaviors Nursing Role in Labor Our role is To assure safe passage through the transition of birth for mother and baby To help birth a new family