Chapter 16/19- Labor and Delivery
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When the baby starts to move down into the pelvic cavity
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Lightening
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2-3 weeks before labor begins
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When does lightening occur
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False labor contractions that are irregular, intermittent and occur throughout pregnancy. They become unmore comfortable close to term.
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What are Braxton Hicks
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Softening of the cervix
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Ripening of the cervix
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A few days before labor
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When does ripening of the cervix occur
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When the mucous plug is expelled, resulting in a small amount of blood loss from the exposed cervical capillaries.
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What is bloody show
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Within 24-48 hours
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How far after the bloody show does labor begin
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The thinning of the cervix. The cervix goes from a long, thick structure to a tissue paper thin structure.
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Effacement
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-Nitrazine paper -Fern test (put it on a microscope slide and if it is amniotic fluid it will look like a fern)
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What is used to determine amniotic fluid from urine after ROM
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CLEAR/ODORLESS, watery
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What color/odor should amniotic fluid have
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Greenish/brown, meconium stained. Fetal hypoxia is a cause of this. The fetus is stressed.
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What does abnormal amniotic fluid look like
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Spontaneous rupture of membranes
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What does SROM mean
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Artificial rupture of membranes
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What does AROM mean
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CHECK FETAL HEART TONES (FHT) for a prolapsed cord
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What do I do RIGHT AFTER ROM
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24 HOURS -If it is longer it could mean infection
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How long after ROM should the mother have her child
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1. The passage 2. The fetus 3. The physiologic forces of labor 4. The relationship between the passage and the fetus 5. The psychosocial considerations
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Five factors important in the process of L&D
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-Contractions are regular -Contractions increase in duration, frequency, intensity -Discomfort starts in the BACK and then radiates to the abdomen -Pain is NOT relieved by walking -Progress cervical dilation and effacement
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True Labor
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-DOES NOT progress cervical dilation and effacement -Irregular -DO NOT increase in duration, frequency, or intensity -Are relieved by ambulation, changes in position, drinking water, or a warm shower -Discomfort occurs in the lower abdomen and the groin
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False Labor
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The time between the beginning of one contraction to the beginning of another
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Frequency
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The time between the start of one contraction to the end of the same one
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Duration
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Strength of the contraction
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Intensity
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****INTRAUTERINE PRESSURE CATHETER***** -You can also estimate by palpating the abdomen during a contraction. -Mild: Tip of nose -Moderate: Chin -Strong: Forehead
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How can you accurately measure the intensity?
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4
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How many stages of labor are there?
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Begins with onset of labor - when the cervix is dilated at 10cm
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What happens in the first stage of labor?
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Latent Active Transition
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What are the three substages in the first stage of labor?
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1-3 dilation Frequency: q10-20 minutes / q5-7 minutes Duration: 15-30 seconds Intensity: mild to moderate
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Latent phase
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Excited Talkative Happy Exhibits indepenence
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How is the mom acting in the latent phase?
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Best time to teach what we are looking for Getting accustomed to the room, monitors Encourage ambulation Void q2-3 hours Start IV Keep couple informed of progress
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Nursing measure in latent phase
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4-7 dilation Frequency: q 2-3 minutes Duration: 50-60 seconds Intensity: moderate to strong
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Active phase
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Increased fatigue More dependent Begins to doubt her ability to cope w/ the contractions **Nurse becomes more active
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How is the mom acting in the active phase?
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Offer pain relief (IV narcotics, epidural) Encourage breathing patterns Quiet environment Void q2-3 hours Provide encouragement, support Back rubs, cool cloth, support w/ pillows, ointment for dry mouth
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Nursing measures in active phase
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8-10 dilation Frequency: q 1 1/2 - 2 minutes Duration: 60-90 seconds Intensity: Strong
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Transition phase
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Increased restlessness and irritability May feel out of control Fear of being left alone
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How is the mother acting in the transition phase?
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Encourage pt to rest between contractions Remain with patient Provide comfort measure (some pts do not wanna be touched) Talk in a calm voice
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Nursing measures for transition phase
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Compete dilation of the cervix - birth of baby
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Second Stage of labor
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May feel helpless, out of control Contractions are not as uncomfortable as in transition phase
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2nd stage - Psychological manifestations
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Assist pt in pushing efforts, what to do, how to do it Give them feeling of control, encouragement Keep informed of progress
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2nd stage- Nursing measures
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Bulging perineum Uncontrollable urge to push Increased bloody show
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Indications of IMMINENT BIRTH
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Birth of baby - birth of placenta
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Third Stage of Labor
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Uterus becomes globular, rises in abd Lengthening umbilical cord Sudden trickle/spurt of blood
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3rd stage - Signs of placental separation
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30 minutes
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The birth of the placenta should be NO LONGER THAN?
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Dry newborn, place under the radiant warmer Assess newborn Identify newborn Instill Erythromycin in the eyes to prevent eye damage from Chlamydia, Gonorrhea Enhance parental bonding
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3rd stage - Nursing measures
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Should be done at 1 & 5 minutes Heart Rate Respiratory Muscle Tone Reflex Irritability Color
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APGAR SCORING
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HIGH SCORE. Highest score is 10
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What is BEST on APGAR SCORING?
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First 1-4 hours after delivery
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Fourth stage of labor
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Wash pt's perineum Apply maternity pad/ice pack MONITOR VS Q15MINUTES 4X Assess fundus, lochia, bladder q15mins 4x Enhance parental bonding **Monitor for bleeding
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4th Stage - Nursing measures
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Extremely rapid labor and birth that lasts for three hours or less
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Precipitous Labor
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Multiparity Large pelvis Previous precipitous labor Small fetus in favorable position
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Causes of precipitous labor
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Notify MD or call 911 Obtain emergency birth pack Scrub and gloves, sterile drape, woman on side Support perineum Rupture membranes if needed Check for nuchal cord Suction mouth and nose Apply gentle downward traction Dry newborn Cut cord Place on mothers abd Inspect placenta
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Nursing Interventions for precipitous labor
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Laceration of cervix, vagina, and perineum Postpartum hemorrhage from lacerations Loss of coping skills
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Precipitous Labor - Maternal Risk
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-Increased pressures on and in the fetal head may cause cerebral trauma -Pneumothorax -Brachial plexus injury -Hypoxi -Nonreassuring fetal status
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Precipitous Labor - Fetal Risks
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-Close monitoring in last few weeks of pregnancy -Induction when cervix ripens -Use caution with Pitocin and discontinue if rapid labor occurs
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Precipitous Labor - Medical RX
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Hypotension Tachycardia Uterine atony Excessive bleeding Hematoma
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What should I immediately report to the MD post birth?
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Refers to the relation of the fetal parts to one another. Curled up in a ball is a normal fetal attitude
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Fetal Attitude
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Longitudinal/Transverse
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Fetal lie
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-Think of "which part presents first in birth" -Vertex presentation: MOST COMMON. Fetal head is presented first, completely flexed onto the chest. -Sinciput presentation (military presentation): Fetal head is neither flexed or extended, top of the head is presenting -Face presentation: Fetal head is hyperextended, face presents -Brow presentation: Fetal head is partially extended, the eyebrows present -Breech: The buttocks or foot is the presenting part -Shoulder presentation: Transverse lie, shoulder is present
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Fetal Presentation
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When the largest diameter of the presenting part reaches or passes through the pelvic inlet
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Engagement
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~~~ 2 weeks before labor
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When does engagement occur
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Refers to the relationship of the presenting part to an imaginary line drawn between the ISCHIAL SPINES (0) of the maternal pelvic. (-5 to +5)
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Station
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By vaginal examination
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How is station determined?
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The relationship between a designated landmark on the presenting fetal part and the front, sides, or back of the maternal pelvis
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Fetal position
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-NORMAL -When the cranial bones overlap under pressure of labor and birth
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Molding
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Spaces between the cranial bones
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Sutures
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Help the MD identify the position of the fetal head during vaginal examination
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Fontanelles
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Diamond shaped Remains unossified for 18 months after birth
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Anterior Fontanelle
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Smaller, triangular shaped Closes 8-12 weeks after birth
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Posterior Fontanelle
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It can cause cervical edema (slows dilation), possible tearing and bruising of the cervix, and maternal exhaustion
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Why should you not bear down if the cervix is not completely dilated?
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YES!
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After giving birth, the mothers WBCs increase to 25,000-30,000, is this normal?
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STERILE
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When membranes are ruptured, do I use clean or sterile gloves?
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Determine frequency in contractions Check status if woman feels urge to push
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During a Sterile Vaginal Exam, what do I do?
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NO
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Do I do a vaginal exam if the patient is reporting painless bleeding?
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YES. DO NOT check too frequently it can increase infection
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Should I use restraint when the membranes are ruptured?
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The placenta is implanted in the lower uterine segment instead of the upper portion of the uterus
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Placenta Previa
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Premature separation of the placenta from the uterine wall
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Abruptio Placentae
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Painless dilation of the cervix without contractions due to a structural defect of the cervix
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Cervical insufficiency
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Surgical procedure in which a stitch is placed in the cervix to prevent a spontaneous abortion or premature birth
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Cerclage procedure
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Situation when there is more than 2,000mL of amniotic fluid
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Hydramnios
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Less than normal (< 500 mL) amount of amniotic fluid
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Oligohydramnios
