labor and delivery-intrapartal
TRANSCRIPT
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Michelle L. Murray, PhD, RNC-OB
Family Nursing 2580
Spring, 2012
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Identify the 2 phases and 4 stages of labor.
Create a plan of care for an uncomplicated labor.
Discuss the collaborative role of the nurse when there is acomplicated labor.
Identify FHR patterns that are ´reassuringµ or Category 1or ´nonreassuringµ or Category 2 or 3.
List 5 things the nurse can do when there is a Category 2 or3 FHR pattern.
Refer to the syllabus for learning content.
Keryotype-chromosome found with amniosythesis
By the end of this semester you should be able to:
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After reading the chapter and by the end
of this seminar you should be able to:
1. List 2 signs of impending labor.
2. Differentiate 3 signs of true vs. false labor.
3. Understand the role of prostaglandins andoxytocin.
4. List 3 signs of preterm labor (PTL).
5. Discuss problems of the 3 Ps: Psyche, Passenger,and Powers.
6. Describe the nurse·s role when a patient has PTLor there are decelerations in the FHR.
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Signs of Impending Labor
False Labor and True Labor
Physiology of Labor
Preterm Labor The 4 Ps of Labor: Psyche, Passenger,
Passageway and Powers
Dystocia
Fetal Heart Rate Monitoring: Overview
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May experience 1 or more: Braxton-Hicks contractions (increase) Backache (Relaxin: peptide hormone breaks
down collagen-widens pubic bone) Lightening: fetus descends (pelvic inlet) Cervical ripening (softening; Relaxin) Bloody Show: mucus plug plus streaks of
blood GI symptoms (possible): D/N/V/indigestion Energy spurt (possible): 24-48 hours prior to
birth ROM: 12% rupture before labor, 80% will go into
spontaneous labor after, if not, expect labor within 12-24hours and induction
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False labor Contractions irregular Walking MAY relieve
contractions
Bloody show usually
not present
No change in dilatationor effacement of cervix
True labor UCs gradually develop a pattern
and intensify over time Myth: UCs are more effective
with walking
Discomfort in lowerback/abdomen
Bloody show often present
Progressive dilation andeffacement of the cervix
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Hormonal changes:
Progesterone decreases
Prostaglandins are
produced
Oxytocin receptors
increase
Oxytocin is released Fetal hormone (oxytocin)
production
Uterine distention (myth)
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4 Stages
2 or 3 Phases
1st Stage
2nd Stage
3rd Stage
4th Stage
1st
Stage: Latent Phase, Active Phase or Latent Phase, Active Phase, Deceleration
Phase
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Not hormones but mediators
Derived from fatty acid (arachidonic acid)that has been acted on by cyclooxygenase
(COX-2) AA + COX-2 PGF2 or PGE2
Cytokines can trigger production of PGs
Increase calcium in the uterine cells
Calcium is a messenger of force
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Oxytocin bound to Oxytocin Receptors
Triggers the production of prostaglandins
PLUS
Increases the amount of calcium in the uterine muscle cells.
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Labor that starts after the 20th week butbefore the end of the 37th week
Etiology not always fully understood
1/3-placental factors, 1/3-infection, 1/3-other Other:
Maternal medical conditions (such as appendicitis)
Use of reproductive technologies/Preeclampsia
Genetics
Social (stress, trauma)
Environmental factors (like what?)
Drugs (especially cocaine)
Demographics (such as?)
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Signs and Symptoms
Often subtle
Intermittent cramps, may or may not be aware or
interpret as painful Low backache; constant, or intermittent, irregular
Pelvic pressure; pressure in vulva or thighs
Abdominal cramps; may have diarrhea
Change or
in vaginal discharge Cervical changes
Cervical effacement of 80% or > or dilatation of > 1 cm
Just not feeling good
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Issues:
Physical
Emotional
Financial
Ethical
In-hospital care
Viability/Gestational Age
Duration of Care
DNR
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Community education Factors that risk Consequences of preterm birth
Prenatal care Importance and access
ID at risk population
Nutrition
Educate: signs and symptoms
Women and significant other:
role in seeking care
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Diagnosis of Preterm Labor
Physician diagnosis (not RN diagnosis)
Call the physician and ask them to come to the bedside
Nurse·s role: physical assessment, may draw blood
and/or submit order for lab studies Set up for SSE (sterile speculum exam)
Bring portable Ultrasound to bedside
Provide Fetal fibronectin (fFN) swab
´The glue that holds the placenta down.µ
A sticky glycoprotein present on the back of theplacenta
Fibronectin receptors in the decidua
Results: Negative ~ 22-37 wks; if positive, risk pretermbirth within 2 weeks
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Physician may assess length of cervix (if vaginalultrasound should be 3 cm +/-)
If less than 25 mm 2.5 cm): vaginal microorganismshave a shorter distance to access the uterus
Infection/endotoxins may weaken membranes,resulting in PPROM (ppreterm ppremature rrupture oof the mmembranes)
RN Role: Assess for signs and symptoms of infectionand rupture
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Nitrazine
Fern test: A positive test shows thepresence of fern-like patterns characteristicof amniotic fluid crystals.
Supplies:
Sterile speculum exam (SSE)and sterile swab Access fluid in posterior fornix (if any)
Avoid collecting mucus (mucus plug)
Clean glass slide
Microscope
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Can Preterm Labor Be Stopped?
Terbutaline (Brethine): Now FDA warning
Antibiotics (of no use once cytokines are
released)
Restrict activity if PPROM
Hydration: if dehydrated to release of AVP(arginine vasopressin/antidiuretic hormone)
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Tocolytics (Beta sympathomimetics/adrenergics)(Ritodrine NOT AVAILABLE & Terbutaline FDA WARNING)
Side effects
HR (often hold if pulse > 120, or per protocol)
Hold and discuss with MD/DO if HTN or hyperthyroidism
or Diabetic Assess V/S, FHR and UA before and after
Breath sounds: shortness of breath, c/o palpitations(most common)
Metabolic changes: check blood glucose levels
Restlessness, tremors, nervousness Usual dose: 0.25 mg SQ (or IVP-dilute first)
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Magnesium Sulfate (IVPB on a pump/buretrol
or volutrol: High-alert medication)
Calcium channel blocker
Decrease calcium - uterine contractions
Off-label use
Excreted in urine (strict I and O)
Assess deep tendon reflexes (DTRs), respiratorystatus, usually OK urinary output (notpreeclamptic)
Criteria to continue: UO 30 mL/hr, presence of
DTRs, min 12 resp/min Mg levels?
Reflexes, respirations, urine output q 1 hour
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Tocolytics Calcium channel blockers ²
Nifedipine (Procardia)
Assess BP closely
Do NOT give close to MgSO4 discontinuation
Prostaglandin Synthesis Inhibitors (COX-2inhibitors) Indomethacin
Toradol (NSAID) Do NOT give after 32 weeks of gestation
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Betamethasone (Celestone)
Corticosteroid
12 mg IM 24 hours apart
23-34 weeks of gestation
To stimulate surfactant development
´For lung maturityµ
45-50% decrease in respiratory distress
Photo from Wikipedia: en.Wikipedia.org/
Wiki/Preterm_birth
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Psyche
Passageway
Passenger
Powers
From:www.vision.ee.ethz.ch
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Factors influencing response
Labor experience: sense of control?
Childbirth preparation Expectations (Birth Plan?)
Identify stressors
Assess coping & support
Be nonjudgmental Support & show respect
Express confidence
Praise efforts
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ANXIETY
Increased Pain
analgesia/anesthesia
Serum epinephrine
Uterine contractility
Length of labor
Apgar
Norepinephrine increases number of contractions
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Signal
Contraction
Unprepared Response Prepared Response
Anxiety, tension
muscular,
visceral
response
Self-image of
being unable to
cope
Inability to
cope;
fragmented,
disorganized
responses
Concentration,
directed motor
activity
Cognitive
responses
Self-image being
able to cope
Continued coping
behavior
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Nursing to anxiety Explore past experiences or family member
experiences
Identify cultural needs
Educate about the process and plan of care Provide supportive care«is there a doula?
Provide personal space
Consider alteration in body image (privacy)
Help maintain control Assess focus of attention, keep informed, allow choices,
Support childbirth prep techniques, reassure
Be a patient advocate
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Orthodox Jewish patients prefer to bring their own food.Nurses can assist by facilitating refrigerator space in thepatient·s room, or on the unit.
One additional issue nurses may encounter is the
completion of birth certificates. Parents will not nametheir son until the baby·s eighth day of life when he isritually circumcised (brit milah or bris).
Girls are usually named in the synagogue by their fatheron the first Sabbath, or on a day during the week whenthe Torah is read.
It may require some flexibility and understanding of thistradition and holding paperwork for parents to returnafter these ceremonies have been completed.
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Establish rapport:
Welcome family, determine family expectations,convey confidence, respect culture
Provide timely interventions
Keep them informed of when you will be in theroom
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Descent through the pelvis
Engagement (tip of skull at level of ischial spines)
Flexion
Internal rotation
Extension
External rotation
Expulsion
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An unengaged fetus at the onset of active
lab
or (nulliparous women) is a risk factor for dystocia.
14% will be delivered by C-section.
Williams Obstetrics, 2005
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THE PELVIS
4 types pelvis shapes
Gynecoid is ideal ~ 50% have
Engaged is when the TIP of
the skull is at the level of the
ischial spines
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Posterior
Anterior
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Dystocia: difficult labor; any labor deviationfrom normal labor pattern; difficult, prolonged,or
abnormal labor
Mechanical Dystocia: due to passenger-passageway FIT problem
Includes Pelvic Dystocia: pelvis too small or
abnl shape Related to a malpresentation (e.g., face or brow) or
malposition (e.g., OT or OP)
Cord prolapse risk
Suspected protraction or arrest of dilatation and/or
descent
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To Mom
To Baby
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Fetus
Placenta
Umbilical cord
Chorion/Amnion (membranes)
and amniotic fluid (500-1500 mL)
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1. Fetal lie: relationship of long axis of fetus to long
axis of mother
± Longitudinal most common
2. Fetal attitude: pose assumed within the uterus
± Flexion most common ± Relationship of fetal body parts to each other
3. Presentation: portion of the fetus coming first
± Cephalic
± Breech
± Shoulder
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Problems with passenger can be R/T:
Fetal anomalies
Presentation
Position
Size
Multiple gestation
Cord
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Fetal anomalies
Fit issues
Photo from www.fetalhydrocephalus.com/hydro/Default.aspx
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Cephalic (Fetal head is presenting)
In addition, presentation can be classified
according to attitude of fetal head and
what is felt by the gloved fingers
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Face/brow
Transverse lie
Breech
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Maternal Risk: C-section
Fetal Risk: cord prolapse
Treatment:
External version
Conscious sedation: Versed and Fentanyl
Possible use of Terbutaline (Brethine)
C-section if version fails or fetus resumes
breech presentation
4% of term fetuses are breech
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´Fetal position has a significant effect on
(the) likelihood of cesarean delivery forboth nulliparous and multiparous women
and this effect is modified by fetal weight.µ
Herrick et al, 2009
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From: www.getdoe.com
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1. A
2. B
3. C
4. D
D B
C
A
You palpate a firm, round form in the fundus,
small parts on the woman¶s right side, and a
long, smooth, curved section on the left side.
Based on these findings, the nurse should anticipate auscultating
the fetal heart in which of the following?
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Macrosomia (4000 grams)
Often leads to cephalopelvic
disproportion (CPD) Treatment?
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17 lb 1 oz Russian baby
delivered by C-section
www.hoax-slayer.com/giant-Russian-baby.shtml
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From: www.catalog.nucleusinc.com
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Placenta Previa
Painless bleeding
PlacentalAbruption
Usually pain Thrombin - more contractions
Bleeding may be hidden
Constant and intermittent pain is possible
Assess location, rate pain, describe characteristics
Notify MD/DO ASAP Start IV
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Hidden (Occult) Partial Complete
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Call for help
Knee-chest or MODIFIED Trendelenburg
Sterile vaginal examination
No funic replacement
Digital displacement of little help
Avoid touching the cord
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Bladder inflation works (if you anticipate adelay to deliver)
400 ² 700 mL (use non-dextrose IVF)
Start IV (If IV in, discontinue Pitocin, IVbolus)
STAY CALM!
If time, monitor the fetus and apply oxygen
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Fig. 17-2
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H ypotonic Uterine Contractions (Inertia) UCs become infrequent and palpate mild
Slow progress
Mechanical Dystocia?
Exhausted mother and uterus?
Infection?
Nursing :
If fetal well-being and low station, AROM
(provider) Oxytocin (Pitocin augmentation)
Ambulation does NOT work!
Hydrotherapy is nice but it is not the solution!
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Functional Dystocia: due to powerproblems
Usually contractions are too few or
too weak, i.e., inadequate power
Nursing role: Notify the provider, document
your assessment of uterine activity
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Induction: Initiating labor by artificial means
Mechanical or medications to ripen the cervix
Oxytocin (Pitocin) after the cervix is ripe
Augmentation:
Enhance weak and well-spaced contractions
Goal:
UC every 2-3 min x 40-60 secondswith interval of at least 1 minute and
resting tone no greater than 25 mm Hg
Pitocin is NOT the solution for mechanical
problems
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Fetal and Maternal Danger if:
Contractions
< q 2 minutes
90 or more seconds
Peak pressure > 90 mm Hg
Resting tone 30 or more mm Hg
FHR may not indicate severity of ischemiaRole of the Nurse:
Decrease or discontinue oxytocin infusion
TITR ATE DOWN or DISCONTINUE
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Hypertonic Uterine ContractionsLatent Phase
Spontaneous Hyperstimulation
Usually mild, frequent, and related to anxiety and/orher bs
Nursing: antianxiety medication, IV bolus, warmbath, rest, pain control (Morphine sleep)
Latent Phase
Tachysystole d/t Exogenous Prostaglandins or Oxytocin
May be related to cocaine use
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Active Phase
UCs too long , too close, too strong (MVUs),
resting tone too high
uteroplacental perfusion deficit precedes
fetal hypoxia, acidemia, acidosis, asphyxia
Fetal aspiration of meconium (not likelywithout fetal gasping after primary apnea,
hypotension, and bradycardia)
maternal pain (decrease or DC Pitocin)
Breakthrough pain (epidural ineffective)
Blood in the urine? Consider fetal-pelvic fit
and fetal position
Maternal Exhaustion, ineffective pushing
Hypertonic Uterine Contractions
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Copyright 2009 Learning Resources Intl Inc.
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POST PARTUM HEMORRHAGE
Blood loss of 500 mL or more
Especially if the uterus is infected after
A prolonged labor and/or
Excessive Pitocin administration
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Mechanicaldystocia withinability of thefetus to passthrough themother·s pelvis
Maternalconditions where
pushing is harmful Active maternal
herpes or HIV
Previous surgery onthe uterus
Fetal compromise
Placenta previa orPlacental abruption
Twins: vtx/breech,or breech/vtx«
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Scheduled, Urgent, Emergent
ScheduledScheduled: to preserve vaginal integrity,
repeat C-section, breech, twins, other
UrgentUrgent : fetal condition likely to deteriorate
(ASAP) Emergency (STAT)Emergency (STAT): no prep, no FoleyFoley,
just go to the OR now; may be under a local if anesthesia is not in house
Psychological impact: anxiety, PTSD
Feelings of dependency/lack of control
Offer support, remember the family,
especially if STAT C-section
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Mother Anesthesia
Respiratorycomplications
Blood clots/DVT Injury to urinary tract
Delayed intestinalperistalsis/ileus
Infection
Hemorrhage Death
Neonate Inadvertent preterm
birth Respiratory problems
because of delayedabsorption of lungfluid
Injury
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Copyright 2011 Learning Resources Intl., Inc.
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Range Category
BL 120-160 bpm 1 or Normal
Tachycardia
Moderate
Marked
> 160 bpm
161-180 bpm
> 180
2 - impending
decompensation
No atrial kick/ischemia and
injury risk
Bradycardia
Moderate
Marked
100-119 bpm
<100 bpm
2 or 3
Ischemia risk/low fetal BP
Accelerations 15 bpm for
15 or more seconds
With variability: 1/normal
Without variability: 3/NRDecelerations
Early
Late
Variable
Nadir depth from BL
10-40 bpm
5-60 bpm
10-60 bpm
Head/brain compression
Placenta: Hypoxia/Acidosis
Cord Compression
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Discontinue oxytocin infusion
Reposition the patient (knee-chest is best,lateral is next best)
Oxygen at 10 L/minute by mask
IV bolus? (consider dangers) Myth: IV fluids to increase maternal volume
Fact: Release of atrial natriuretic peptide -a smooth muscle relaxant
Communicate: Charge nurse and CNM orMD/DO
SVE to check for a baby (vs. cord)
Consider route and timing of delivery
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The End