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Chapter 12--Processes & Stages of Labor and Birth

Maternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton Hisley1Critical 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 bones3PassengerFetus and fetal membranes Molding of headFetal lieLongitudinalTransverseObliqueRefer to Box 12-2 for fetal skull landmarksRefer to Figure 12-4 for Fetal Lie4

5Fetal 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)

6Passenger (cont.)Fetal attitudeflexionFetal presentationCephalicVertexMilitaryBrowFace7

Fetal Attitude8Advantages of Cephalic PresentationsHead usually largest part of infantMoldingOptimal shapesmooth and round9Assessment: 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

Breech presentation10Disadvantages of Breech PresentationRisk of cord prolapsePresenting part less effective in cervical dilationRisk of cord compressionRisk of prolonged labor11Shoulder PresentationOccurs when fetus in transverse lieCannot be delivered vaginally unless rotation occursRefer to Figure 12-8 for Shoulder presentation

12IMPORTANT TERMSEffacement: shortening and thinning of cervixExpressed as a percentage (0% to 100%)Dilation: opening and enlargement of cervixExpressed in centimeters (1 to 10 cm)13

EffacementThinning of cervix(in %)StationDescent of fetal head(in cm)14

Descent offetal head:

StationFloatingEngagedAt outlet/crowning15Passageway +Passenger RelationshipEngagement StationIschial spines0 stationAbove ischial spines() minus stationBelow ischial spines(+) plus station+4 cm means that ...Refer to Figure 12-9 for station16PowersUterine contractionsprimary forceMaternal pushing effortssecondary forceCharacteristics of uterine contractions IncrementAcmeDecrement17 Powers Maternal Pushing EffortsBearing down sensationUrge to pushNo urge to push18Assessment of Uterine ContractionsCharacteristicsFrequencyDurationIntensityPalpationElectronic fetal monitoringRefer to Figure 12-1 for Intensity19Onset 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 energy20False 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

21False 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

22 Critical 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 23 First Stage of Labor: 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

24Landmarks Abbreviations are used First and last lettermaternal pelvisMiddle letterfetus presenting partExamples ROA (right occiput anterior) ROPLSP25 Psychosocial InfluencesOther critical factorsReadiness, educational preparedness, etc.Cultural views of childbirthRole transition facilitated by positive childbirth experienceNegative experience interferes with bonding and maternal role attainment26Childbirth Settings and Labor Support 27Admission ProceduresEstablish positive relationshipCollect admission dataInitial admission assessmentsFocused Psychosocial assessmentCultural assessmentLaboratory testsRefer to Table 12-2 for circumstances that warrant going to birthing center28Nursing CareOngoing assessmentFacilitate a positive birth experienceManage discomfortAdvocate for patients needsProvide anticipatory guidance29Care of Laboring Patient Early 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 manageable30Care 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 increasing31Labor SupportPresencePromote comfortEnvironmentPersonal hygieneEliminationSupportive relaxation techniques32Critical 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

33Fetal AssessmentPositionFetal heart soundsBaseline FHRPresence ofVariabilityAccelerationsDecelerationsRefer to Figure 12-17 for accelerationsRefer to Figure 12-18 for decelerations34Interpretation of FHR TracingsConsider contraction frequency and intensity, stage of labor, and earlier FHR patternReassuringNon-reassuringRefer to Box 12-4 for Reassuring v. Non-reassuring35Nursing CareFHR decelerationsEarly: no actionVariable and lateLateral position changesOxygen per face maskPalpation for hyperstimulationDiscontinue oxytocinIncrease IVF rate36Second Stage of LaborFull dilation through birth of infantUrge to pushPromote effective pushingClosed-glottis Open-glottisPosition of comfort37Preparation for BirthBulging of the perineum and rectumFlattening and thinning of the perineumIncreased bloody showLabia begin to separate38Dilatation & Effacement

39Imminent BirthCrowningBurning sensationIntense pressure in rectumRefer to Figure 12-21 for CrowningRefer to Figure 12-22 for Episiotomy40

Mechanisms of labor. A, Descent. B, Flexion. C, Internal rotation. D, Extension. E, External rotation.Cardinal Movements of Birth41Head Rotation during Descent

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CrowningIn the hospitalAlternative settings

Crowning43Nursing Diagnoses for Intrapartal PatientPainKnowledge deficitAnxietyFatigueRisk for infectionImpaired fetal gas exchange44Third StageBirth of baby to complete delivery of placentaSmaller, spherical uterusElevation of uterus in abdomenLengthening and protrusion of cordGush of blood from vaginaRefer to Figure 12-25 for Schultze & Duncan Manner 45Fourth StageDelivery of placenta through 1 to 2 hours after birthMonitor position and firmness of uterusBoggy, soft uterusReport immediatelyInitiate fundal massageAssess lochiaVital signs and urine outputShiveringoffer blankets

46Fourth Stage Risk Signs Hypotension Tachycardia Excessive bleeding Noncontracting uterus 47Chapter 13Promoting Patient Comfort During Labor and BirthMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton Hisley48Pain During Labor and BirthShaped by past experiencesAssessing painPhysiological, psychological indicatorsPatient responsesMay be intensified by fear, anxiety, fatigue49Physical Causes of PainLabor and BirthMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton Hisley50Pain NeurologyUterine ischemiaVisceral paindull and achingReferred painSomatic painsharp, burning, prickling51Pain Perception and ExpressionHighly personal and subjectiveAffected by gender, culture, ethnicity, and past experiencesPhysiological/affective expressionIncreased catecholaminesIncreased blood pressure and heart rateAltered respiratory pattern52Factors Affecting Maternal Pain ResponsePhysicalPhysiologicalPsychologicalAnxiety, fear, previous experienceSupport systems, childbirth preparationEnvironmental53NonpharmacologicalPain Relief MeasuresMaternal position and movementBreathing techniquesMusicRelaxation techniquesOther attention-focusing strategiesGuided imagery54Massage and TouchEffleurageCounterpressureTherapeutic touchHealing touch55Other Therapies for ComfortHydrotherapy, hypnotherapy, aromatherapyApplication of heat and coldBiofeedback, TENS, intradermal water blockAcupressure/acupuncture56Pharmacological Pain Relief MeasuresTimingNonpharmacological and pharmacological measures promote positive experienceInformed consent

57Pharmacological MeasuresSedatives and antiemeticsSystemic opiods & analgesics

58Nerve Block Analgesia, AnesthesiaRegional anesthesia- EpiduralLocal perineal infiltration anesthesiaPudendal nerve blockSpinal anesthesia blockComplications: maternal hypotension, decreased placental perfusion, ineffective breathing pattern59Systemic 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)60Regional Anesthesia Definition: Injection 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 HAContraindications: coagulation disorders, low platelet count (< 100), allergy, neurologic disease, aspirin or heparin useNursing care: Preload IV fluids (LR), monitor BP, HR, anesthesia level, FHR, foley catheter, maternal positioning61Maternal HypotensionPreventionPreload IV fluidsRequires constant nursing attendanceMonitor vital signs

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Epidural Anesthesia63Postdural Puncture (Spinal) HeadacheLeakage of cerebrospinal fluidIntensified in upright positionAuditory and visual problemsAutologous epidural blood patch Discharge instructions64Disadvantages of EpiduralLimited mobilityCommon side effectsAccidental injection into blood vesselSympathetic blockageUrinary retention, bladder distention

65General AnesthesiaMajor risks used ONLY in emergenciesPre-operative preparationAnesthetic gases and medicationsRecovery room nursing careRefer to Box 13-3 for obstetric complications requiring surgical intervention66Nursing Care Related to Comfort MeasuresAssessmentOngoing and collaborativeDiagnosesAnxietyIneffective copingAcute pain67Nursing CareExpected outcomesPlan of careIndividualizedModified as neededCollaborative approach

68Chapter 14 Caring for the Woman Experiencing Complications During Labor and BirthMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton HisleyRefer to Box 14-1 for possible nursing diagnoses69DystociaLong, difficult, or abnormal laborMay arise from Powers PassengerPassageway

Refer to Box 14-2 for Dystocia70Dysfunctional Labor Pattern: HypertonicStrong, painful, ineffective contractionsContributing factormaternal anxietyOcciput-posterior malposition of fetusManagementRest, hydration, sedationFacilitate rotation of the fetal head

Refer to Figure 14-1 for Hypertonic & Hypotonic71Dysfunctional Labor Pattern: HypotonicContractions decrease in frequency and intensityMaternal and fetal factors that produce excessive uterine stretchingManagementWalking, position changesAugmentation of labor 72Precipitate Labor and BirthRapid labor & birthNursing considerationsCareful examination for dilation and effacementReassure woman and support personBreathing to avoid pushing and prevent tearingCareful examination of maternal soft tissue and placenta73Pelvic Structure AlterationsPelvic dystociaSoft tissue dystociaTrial of laborTo assess safety of vaginal birth74 Obstetric Interventions AmniotomyArtificial rupture of membranesAugment or induce laborNursingCareful monitoring of vital signs, cervical effacement/dilation, station, FHR, contractionsDocument regarding amniotic fluid75Obstetric InterventionsAmnioinfusionRisks: infection, overdistention of uterus, increased uterine toneNursing Careful monitoring of infusion, intensity and frequency of contractions, and maternal vital signsEducatePharmacological induction of laborNonpharmacological stimulants of labor76EpisiotomyMidline or mediolateralNursing care:Assess for approximation, swelling, oozing, infectionRelief for pain: ice pack in first 24 hours, then heat, local analgesic spray, witch hazel pads (Tucks), sitz bath, peri-bottle for voiding, pain medications

77Induction of LaborIndications for inductionBishop scoreCervical ripening agentsMechanical methodsOxytocinAugmentation of laborRefer to Table 14-1 for Bishop scoring system78InductionNursing ConsiderationsInformed consentCareful monitoring of laborDiscuss pain relief measuresPosition changesKeep patient and support person informed of progress79ForcepsIndications: 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/bruisingInstrumentation Assistance of Birth80

81 Maternal Complications

Hypertensive DisordersPreeclampsia-eclampsia, HELLP syndrome NursingCareful assessmentsMonitor lab valuesAdminister platelets as appropriateOngoing education

Refer to Box 14-3 for fetal-maternal factors that necessitate immediate interventionsRefer to Box 14-4 for Key parameters to be monitored82 Maternal ComplicationsDiabetesFetal lung maturityIntrapartum management-Maternal hydration, -Insulin, and -Blood glucose levelsLabor: normal progression of laborUpright or side-lying positionEncourage breastfeeding83Preterm Labor and BirthCareful maternal monitoringFHR monitoring ***Identify and report symptoms suggestive of fetal hypoxiaAssess psychological status84 Labor and Birth ComplicationsFetal Fetal malpresentationVersion: external or internalShoulder dystociaCephalopelvic disproportionMultiple gestationNon-reassuring FHR patternsRefer to Figure 14-6 for VersionRefer to Figure 14-7 for McRoberts maneuver

85Macrosomia/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 baby86

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

87McRoberts Maneuvers Video

88 Amniotic Fluid ComplicationsOligohydramniosHydramniosMeconiumNuchal cord89Other ComplicationsUterine ruptureObstetric emergencyUterine inversionUmbilical cord prolapse

90Collaboration in Perinatal EmergenciesMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton HisleyRefer to Box 14-5 for team expectation in obstetric emergency91 Perinatal Fetal LossWhat to sayWhat NOT to sayNursing considerations < 20 weeks> 20 weeks name & hold the baby funeral/memorial service Resolve support group92 Cesarean BirthIndicationsHealth of mother or fetus is jeopardizedEthical considerationsSurgical proceduresSurgical and postoperative careVaginal birth after cesarean93Cesarean 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 gestation94Cesarean 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 reactionsDeepVeinThrombophebisBleedingUreteral/bladder injuryIncrease risk for subsequent pregnancyPlacenta Acreta/Previa, Infertility95

96 Postterm Pregnancy> 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), induction97Post-Op CareAssess fundus/bleeding, vital signs, DVT.Antibiotics, if infection 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.

98Critical 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.

99 Case Study: Linda MandellaLinda Mandella is in labor with her third baby at the birth center. She wishes to experience a natural, unmedicated birth. Linda is groaning and crying. A cervical examination performed 2 hours ago revealed that she was 6 cm dilated, and 100% effaced. Lindas family is present, and this is the first time that they have been able to attend and support her during the labor and birthing process. The family members are shouting and blaming the nurse for causing Linda to suffer. They demand that the nurse give Linda painkillers to ease her suffering and pain. Critical Thinking Questions1. What are the priority nursing diagnoses at this time?2. What are the expected outcomes associated with these diagnoses?3. Describe the teaching/learning needs related to the scenario that correspond to the priority nursing diagnoses.4. List nursing interventions with rationales that correspond to the priority nursing diagnoses.