Exam 9: Nursing Care During Labor and Birth
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| CURRENT SETTINGS FOR CHILDBIRTH: Traditional | Small functional room for labor
Moved to delivery area
Transferred to recovery area
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| CURRENT SETTINGS FOR CHILDBIRTH: To Postpartum Unit | Advantage: safe
Disadvantage: impersonal, multiple moves, uncomfortable for mother, disrupts family ‘s time together, separate parents and infant,
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| CURRENT SETTINGS FOR CHILDBIRTH: Labor, Delivery, and Recovery Rooms (LDR) | One setting for labor, delivery and recovery
Remain in LDR for 1 to 2 hours
Advantage: home-like and comfortable, healthy infant remains with mother throughout stay
Disadvantage: Family may regard technologic components as disadvantages
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| CURRENT SETTINGS FOR CHILDBIRTH: Labor, Delivery, Recovery, and Postpartum Rooms (LDRP) | Similar to LDR
Not transferred to a postpartum unit after recovery
Advantage: support person encouraged stays with the mother and infant, sleeping equipment may be provided
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| CURRENT SETTINGS FOR CHILDBIRTH: Birth Centers | Designed to provide maternity care to low-risk women outside the hospital setting.
Advantage: less expensive, safe and home-like setting for the low risk women
Disadvantage: Not equipped for major obstetric emergencies.
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| CURRENT SETTINGS FOR CHILDBIRTH: Home Birth | Home Births
Advantage: keeps family together in own environment
Disadvantage: Long transfer time to hospital in an emergency
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| Guidelines for Reporting to a Birthing Facility | Contractions
Ruptured membranes.
Bleeding other than bloody show.
Decreased fetal movements.
Other concerns.
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| Guidelines for Reporting to a Birthing Facility: Contractions | 5 minutes apart for 1 hour for first labor.
10 minutes apart for 1 hour for second and subsequent labors.
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| What is the primary advantage of the traditional hospital setting? | : It is safe. All emergency equipment and personnel are readily available.
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| Traditional Practices of Various Cultural Groups: SE Asia | (China, Japan, Korea):
Father usually is not present.
Stoic response to pain.
Side-lying position preferred.
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| Traditional Practices of Various Cultural Groups: Laos | Squat for birth.
Prefer female attendants.
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| Traditional Practices of Various Cultural Groups: India | Natural childbirth methods used.
Female relatives present as caregivers.
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| Traditional Practices of Various Cultural Groups: Iran | Father not present.
Female caregivers and support people present at birth.
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| Traditional Practices of Various Cultural Groups: Mexico | Stoic about pain until second stage.
Father and female relatives present.
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| Traditional Practices of Various Cultural Groups: American Indians | Bury placenta for good luck.
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| Cultural Assessment | Assess the personal expectations and values of each woman and her support person about birth in different groups.
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| Why is it important to ask a laboring mother about her specific cultural practices | It provides a framework to assess and care for the woman and her family as individuals. A woman’s anxiety level rises when she does not understand what is happening to her or what is being said.
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| When should a woman report to the birthing facility? | Contractions: 5 minutes apart for 1 hour for first labor. 10 minutes apart for 1 hour for second and subsequent labors.
Ruptured membranes.
Bleeding other than bloody show.
Decreased fetal movements.
Other concerns.
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| Maternal physiologic changes | Cervix thins and dilates.
Supine hypotension may occur during labor if the woman lies on her back.
Depth and rate of respirations increase. Hyperventilation may occur.
Reduced sensation of a full bladder.
Decreased GI motility may have N/V.
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| Fetal physiologic changes: Placental circulation | due to compression by the uterine muscle the maternal blood supply to the placenta decreases
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| Fetal physiologic changes: Cardiovascular | Changes reflect normal labor effects or suggest fetal intolerance
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| Fetal physiologic changes: Pulmonary | Lung fluid must be cleared to allow normal breathing after birth.
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| Four Ps: Components of the Birth Process | Powers.
Passage.
Passenger.
Psyche.
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| Powers | Involuntary uterine contractions which cause the cervix to open and that propel the fetus downward through the birth canal.
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| Primary powers | Responsible for effacement and dilation of the cervix.
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| Secondary powers | Bearing down efforts of the woman which add to the power of the expulsive forces but have no effect on cervical dilation.
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| Powers; Contractions | Coordinated uterine contractions are the primary powers of labor during the first stage.
Contractions are involuntary.
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| Effects of Contractions | Cervical Effacement.
Cervical Dilation.
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| Cervical Effacement | Effacement is thinning of the cervix and is described as a percentage of the
Original length of the cervix, i.e. 50% effaced.
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| Cervical Dilation | Dilation is the enlargement or widening of the opening of the cervix and the cervical canal. It increases from less than 1 cm to 10 cms.
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| Characteristics of Contractions: Frequency | The elapsed time from the beginning of one contraction until the beginning of the next contraction.
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| Characteristics of Contractions: Duration | The length of each contraction from the beginning until the end of the same contraction.
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| Characteristics of Contractions: Intensity | The strength of the contraction as externally palpated.
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| Characteristics of Contractions: Interval | The period of time between the end of one contraction and the beginning of the next.
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| Physiology of Contractions | Increment.
Acme or Peak.
Decrement.
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| Hypertonic (tachysystole) contractions: | Less than 2 mins apart.
Longer than 90-120 secs.
Intervals shorter.
Incomplete relaxation of the uterus.
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| Maternal Pushing | When the cervix is fully dilated the combination of the contractions and the maternal pushing propel the baby downward through the pelvis.
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| Factors affecting pushing | Maternal exhaustion.
Epidural anesthesia.
Some women may want to push prematurely due to the fetal head causing rectal pressure.
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| The Passage | Bony pelvis and the soft tissues of the pelvis and perineum.
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| Bony pelvis: | False pelvis.
True pelvis.
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| Soft Tissues: | Uterus
Cervix
Vagina
Perineum
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| Uterus: | During labor the walls of the upper uterus thicken while those of the lower uterus become thinner.
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| Cervix: | Dilates in response to the contractions.
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| Vagina: | Capable of stretching to allow passage of the fetus.
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| Perineum: | The muscles are stretched and thinned by the pressure of the fetus.
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| The Passenger | Includes the fetus along with the placenta and membranes.
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| The fetus | Usually enters the pelvis head first.
The bones in the skull are not fused allowing the boney plates to move and overlap as they go through the birth canal (Molding).
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| Fetal Lie | The relationship of the fetal head and buttocks axis to that of the mother.
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| Fetal Lie: Longitudinal | Most common.
99% of deliveries.
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| Fetal Lie: Transverse | 1% of deliveries.
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| Fetal Attitude | The relationship of fetal body parts to one another.
The ideal attitude is where the back is bowed outward, chin touches the sternum and arms are crossed on the chest with thighs flexed onto the abdomen.
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| The Psyche | Crucial part of childbirth.
Marked anxiety and fear decrease a woman’s ability to cope with pain in labor.
Catecholamines inhibit uterine contractions and divert bloodflow from the placenta.
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| How are dilation and effacement estimated? | Effacement is the thinning of the cervix, described as a percentage of the original length of the cervix from 0 -100%.. Dilation is the enlargement or widening of the opening of the cervix and the cervical canal from 1cm – 10 cm.
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| What is used to describe how the head is oriented if the fetus is head down? | Fetal presentation. Designated as cephalic or vertex
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| True Labor | Contractions:
Regular.
Closer together.
Stronger.
Last longer.
Contractions start in lower back and then lower abdomen
Contractions cannot be stopped.
The cervix softens, effaces and dilates.
The fetus descends into the pelvis.
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| False Labor | Contractions:
Rarely follow a pattern.
Vary in length and intensity.
Contractions frequently stop with ambulation and position changes and eventually stop with relaxation interventions.
Discomfort in abdomen and groin
The cervix does not change.
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| Nursing Care r/t False Labor | Focused Assessment:
Fetal heart tones.
Maternal vital signs.
Presence and frequency of contractions.
Observation.
Discharge.
Review guidelines for returning.
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| Admission Assessments: Fetal Condition | The fetal heart rate (FHR), regular rhythm.
The normal average FHR is 110-160 beats/min with 6-25 beat fluctuations.
Presence of accelerations and absence of decelerations.
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| Admission Assessments: Status of Amniotic Membranes | Ruptured Membranes.
Observe time, amount, color and odor.
Confirm ruptured membranes.
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| Ruptured Membranes | SROM.
AROM.
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| Confirm ruptured membranes with: | Nitrazine paper.
Fern test.
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| Admission Assessments: Maternal Condition | Assess vital signs:
-BP
-Assess for hypertension.
-Goal is BP less than 140/90.
-Temperature
-Assess for signs of infection.
-Temp above 38 C (100.4 F) should be reported
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| Admission Assessments:Impending Birth | Observe for signs or behaviors that suggest she is about to give birth:
Sitting on one buttock.
Making grunting sounds.
Bearing down with contractions.
Stating “The baby’s coming”.
Bulging of the perineum.
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| Additional Assessments | Prenatal care
Obstetrical and medical-surgical history.
Allergies.
Food intake.
Any recent illness.
Medications.
ETOH and drug use.
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| Woman’s plan for birth | support person, planned pain management methods
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| Status of Labor | Cervical dilation and effacement.
Fetal presentation, position, and station.
Contractions are assessed for frequency, duration and intensity.
Evaluation of membrane.
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| Admission Procedures: Consent Forms | Anesthesia.
Vaginal delivery and/or cesarean section.
Blood transfusion.
HIV testing.
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| Admission Procedures: Laboratory Tests | Blood for hematocrit (CBC usually sent) and midstream urine specimen for glucose and protein are obtained.
HIV status, ABO and Rh type.
Women with no prenatal care will have additional labs drawn such as drug screen.
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| Admission Procedures: Intravenous infusion | an IV line allows administration of fluids and drugs. Usually started with an 18 gauge catheter.
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| Process of Childbirth: Impending Labor | Braxton-Hicks contractions.
Increased vaginal discharge.
Bloody show.
Rupture of membranes.
Energy spurt.
Small weight loss.
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| Process of Childbirth: Mechanism of Labor | Descent.
Engagement.
Internal rotation.
Extension.
External rotation.
Expulsion.
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| Stages of birth: Station | How far down the baby's presenting part is in the pelvis. Station zero is the middle of the pelvis. A negative number indicates that the baby is still higher, while a positive number means the baby's head has made its way through the pelvic inlet.
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| Stages of Labor: First Stage; Dilation | Begins with the onset of contractions until full dilation of the cervix (10cm).
This is the longest stage for both the nullipara and multipara.
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| First Stage: Dilation (3 Phases) | Early Latent.
Mild/Active.
Transitional.
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| Early Latent Phase | 0 - 3 cm.
Contractions mild and infrequent.
Gradually increased strength & intensity.
Woman sociable & excited; cooperative but anxious.
Pain is usually mild at this phase
Duration 30 to 40 seconds.
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| Mild/Active Phase | 4 - 7 cm.
Complete effacement.
Contractions moderate to firm every 2-5 mins
Duration 40-60 seconds.
Contraction intensity & frequency increase.
Woman less sociable, turns inward.
May ask for pain medication.
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| Transitional Phase | 8 - 10 cm.
Shortest phase.
Contractions firm; q 1.5 to 2 min. & lasting 60 to 90 seconds.
Woman may become uncooperative & hostile; feeling of losing control.
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| Nursing Interventions: Stage 1 | Assist with maintaining concentration and support her coping techniques.
Encourage the laboring woman and her support person especially during the last phase.
Woman feel the urge to push, but shouldn't because the cervix not fully dilated at this st
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| Second Stage: delivery. | Dilation to birth.
53 to 57 minutes or 79 minutes with epidural for nullipara;17-19 minutes with no epidural or 45 with it for multiparas.
Contractions firm; slightly less frequent & shorter duration.
Urge to push with each contraction.
Regains contro
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| Types of Episiotomy | Midline Episiostomy. Straight up and down.
Mediolateral Espisiostomy: Off to the side.
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| Nursing Interventions: Stage 2 | Encourage the mother to push effectively.
Give praise.
Provide comfort measures as needed.
Offer pharmacologic measures for pain management.
Be informative, but neutral.
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| Third Stage: delivery of the Placenta. | Begins with delivery of baby and ends with delivery of the placenta.
Average time is 5 to 30 minutes.
Uterine contraction controls bleeding.
Oxytocin & breastfeeding stimulate contractions.
Minimal pain; cramping.
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| Nursing Intervention: Stage 3 | Massaging the uterus to firm it up and compress open vessels at the placental site.
Assess uterine tone with each set of vital signs.
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| Fourth Stage: stabilization. | 1-4 hours following birth.
Monitor physiologic changes closely.
Vital signs, uterine tone, vaginal drainage and assessing perineal tissue are important during this time.
Assess bladder for fullness.
Assess for s/s of hemorrhage by assessing lochia.
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| Stage 4: Infant Assessment | Assess Apgar score at 1 and 5 minutes.
Monitor infant:
Vital signs.
Support thermoregulation.
Place ID bands.
Complete assessment within 1 hour.
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| Stage 4: Mother Assessment | Monitor Mother:
Vital signs, fundus, bladder, lochia.
Promote comfort.
Promote bonding and assist with breastfeeding as needed.
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| Precipitous Labor | Labor that is completed in less than 3 hours.
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| Precipitous Labor: S/S | Labor begins abruptly and intensifies quickly.
Contractions may be frequent and intense.
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| Precipitous Labor Risks: Maternal | Uterine rupture.
Cervical/vaginal lacerations and hematoma.
Amniotic fluid embolism.
Postpartum hemorrhage.
Abruptio placentae can be associated with precipitate labor.
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| Precipitous Labor Risks: Fetal | Hypoxia resulting from decreased periods of uterine relaxation between contractions.
Intracranial hemorrhage.
Nerve damage.
Low apgar scores.
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| Precipitous Labor: Nursing Interventions | Promote fetal oxygenation.
Pain control.
Reducing anxiety.
A tocolytic may be ordered
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| Precipitous Birth | Birth that occurs unexpectedly, with no trained birth attendant present. Precipitous birth may occur after a labor of any duration.
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| Precipitous Birth: Nursing Priorities | Prevent or reduce injury to the mother and infant.
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| Nursing Interventions | Provide as much privacy as possible for the woman.
Locate precip tray.
Do not leave woman alone.
If time allows wash hands, wear gloves if available.
Do not attempt to prevent delivery
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| SIGNS OF PLACENTAL SEPARATION: | -a gush of blood
-cord appears to lengthen
-the uterus has a spherical shape
--the uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward.
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| What happens if the cord is too tight to slip over the head? | CLAMP IN TWO PLACES AND CUT BETWEEN CLAMPS.
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| What is it called when a birth occurs unexpectedly, with no trained birth attendant present? | PRECIPITOUS BIRTH.
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| Fetal Heart Rate Assessment: Intermittent Auscultation | Allows greater freedom of movement.
Only method possible if the mother is using a whirlpool or shower during labor, and method used with home deliveries.
Intermittent auscultation is used to collect data about the fetus during a small part of labor.
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| tinuous Electronic Fetal Monitoring (EFM) | Allows the nurse to collect more data about the fetus than intermittent auscultation.
Written recording that becomes part of the mother’s chart.
A disadvantage is that it hampers ambulation.
Show how fetus responds in labor.
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| Continuous Electronic Fetal Monitoring (EFM): External Devices |
External fetal heart monitoring is done with a Doppler transducer.
Contractions are sensed externally with a toco-transducer (TOCO), with a pressure-sensitive button.
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| Continuous Electronic Fetal Monitoring (EFM): Internal Devices (FSE) | Fetal Spiral Electrode.
Membranes must be ruptured/cervix dilated.
Detects electric signals from fetal heart.
Penetrates fetal scalp.
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| Continuous Electronic Fetal Monitoring (EFM): Internal Devices (IUPC) | IUPC – 2 types
A fluid filled catheter connected to a pressure-sensitive device on the monitor or
A solid catheter with a pressure sensor in its tip
Internal devices require that the membrane be ruptured and the cervix is dilated 1-2 cm.
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| Evaluating Fetal Heart Rate Patterns: Monitor Paper | FHR is recorded on the upper grid of the paper.
Contraction pattern is recorded on the bottom grid.
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| FHR is evaluated for... | Baseline.
Variability.
Periodic changes.
Accelerations.
Decelerations
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| Baseline | the average heart rate rounded to 5 bpm, measured over at least 2 min within a 10-min window. Uterus must be at rest. Normal baseline at term is 110-160 bpm.
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| Bradycardia | less than 110 bpm, persisting for at least 10 min.
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| Tachycardia | more than 160 bpm, persisting for at least 10 min.
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| Variability | describes fluctuations in the baseline rate that cause the printed line to
have an irregular rather than smooth appearance.
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| Periodic Patterns | transient and recurrent changes from the baseline rate associated with contractions.
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| Acceleration | an abrupt, temporary increase in rate by at least 15 beats/min lasting for at least 15 seconds. They suggest a fetus that is well oxygenated.
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| Early Decelerations | a gradual, rather than abrupt, decrease from the baseline.
occur with contractions. FHR returns to baseline by the end of the contraction.
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| Variable Decelerations | : conditions that reduce flow through the cord may result in variables.
occur during or between contractions. Their shape, duration and depth vary. They fall and rise abruptly.
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| Late Decelerations | deficient exchange of oxygen and uteroplacental insufficiency may result in late decelerations.
occur with peak of contractions. FHR returns to baseline after the end of the contraction.
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| Variability occurs | because of push-pull influences on the fetal heart rate
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| Evaluation of variability | helps clarify how well oxygenated the fetus is during labor.
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| Variability is classified as | Absent/Minimal
Moderate
Marked variability
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| Absent/Minimal | undetectable to less than or equal to a variation in FHR of < 5 beats per min.
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| Moderate | a variation in FHR of 6-25 beats per min.
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| Marked variability | a variation in FHR > 25 bpm.
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| SROM | Spontaneous Rupture Of Membrane
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| AROM | Artificial Rupture Of Membrane
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| Evaluating Contraction Patterns | Frequency
Intensity
Duration
Uterine resting tone
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| Nursing Response to Monitor Patterns (Reassuring) | Accelerations are reassuring and require no intervention.
Early decelerations are caused by head compression and require no intervention other than continued observation.
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| Nursing Response to Monitor Patterns (non-reassuring): Variable decelerations are caused by cord compression. | Repositioning the woman is usually the first response. Several position changes may be necessary before the pattern improves.
Amnioinfusion may be used to increase the fluid around the fetus and cushion the cord.
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| Late Decelerations are caused by | Placental Insufficiency.
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| Non-reassuring patterns are initially treated by measures to increase | maternal oxygenation and blood flow to the placenta
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| Nursing Response to Monitor Patterns (non-reassuring): First Intervention | Repositioning. (Placental insufficiency is often caused by supine hypotension).
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| Nursing Response to Monitor Patterns (non-reassuring) |
O2 at 8-10L/min per SFM
Stop Pitocin if it is infusing.
Treat hypertonic contractions with terbutaline if ordered.
Notify the doctor of any non-reassuring fetal pattern
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