Labor and Delivery Notes PDF

Preview

Summary

Download Labor and Delivery Notes PDF

Description

NUR 1421 Unit 2

Normal Labor and Delivery General Outcome 2.1

On the successful completion of this unit the learner will summarize and prioritize the care of the client experiencing normal labor and delivery.

Specific Learning Outcomes 2.2 The learner will define key terms relating to labor and delivery. 2.3 The learner will describe various patient responses and treatments during the 4 stages of labor for the following: Stages 1

Physiologic response Latent/Early Phase -

-

-

Onset of regular contractions; cervix begins to dilate & efface Uterine contractions ↑ in frequency, duration, & intensity Start mild – lasting 20-40 sec w/ frequency of 10-30 min.

Active Phase - Cervix dilates about 4-7 cm -

Fetal descent progressive

-

Multiparous dilate faster than nulliparous women

-

Contractions have frequency of 2-5 min, duration of 40-60 sec & moderate-strong intensity

Psychologic response -

Feels she is able to cope w/ discomfort

-

Relieved labor has started

-

Anxious, able to express feelings of anxiety

-

Talkative, smiling, eager

-

Excitement is high

-

Anxiety ↑ as contraction and pain intensify Fears a loss of control ↓ ability to cope, sense of helplessness

-

-

Last part of 1st stage Dilation averages 0.5 cm/hr for nulliparous & 0.3 cm/hr for multiparous

Significant anxiety; inner directed and tired Aware of ↑ force/intensity of contractions

-

Rate of fetal descent increases

Restless, frequent position changes

-

Duration of 1st stage may ↑ if epidural used

Fear being left alone

-

-

Contraction frequency of 1.52 min, duration of 60-90 sec, & strong intensity Approaching 10 cm, ↑ rectal pressure, bloody show, ROM, & uncontrollable urge to bear down

- Women w/ support have greater satisfaction & less anxiety -

Transition Phase -

Partner/suppor t response - Often as elated as the women is

Fear of being “torn open” or “split apart” by the force ↑ abd pressure from contraction  abd burst open? w/draw into herself, ↑ doubt ability to cope w/ labor apprehensive, irritable, terrified of being alone, no one touch/talk to her may ask for physical/verbal support for next contraction; help regaining focus

Feeling the need for a break     Ensure pt she will not be left alone

Normal sensation; reassure

Start to feel helpless, turns to nurse for ↑ participation as there efforts to ↓ her discomforts seem less effective

anxious to “get it over with”

1 of 12

NUR 1421 amnesic and sleep between contractions 2

Begins when cervix is completely dilated (10 cm) & ends w/ the birth of neonate - Contractions continue w/ a frequency of 1.5-2 min, duration of 60-90 sec, & strong intensity -

Descent of fetus continues until it reaches perineal floor

-

Feel an unbearable urge to begin pushing, other may not

Childbirth prepared women feels relieved pain felt in transition phase is over Relieved birth is near and now can push Feels sense of control W/o childbirth prep, they become frightened - Tend to fight each contraction and others telling her to push -

Women w/o urge encourage to relax and let baby “labor down” -

Sensation to push  rectal pressure

-

Women w/ epidural: reduce rate for return of feeling/instinct to push restored

-

Intra-abdominal pressure exerted from contraction of abd muscles

Push naturally w/ open glottis  5 sec of sustained pushing for 35x/contraction -

Perineum begins to bulge, flatten, & move anteriorly

-

Bloody show ↑

-

Labia begin to part, fetal head appears to recede

-

Crowning occurs  feel acute ↑ severe pain & burning sensation

Spontaneous Birth (vertex pre.)

-

Feels she lost control, becomes embarrassed & apologetic or shows extreme irritability toward staff & supporters Feels helpless

Behavior may be frightening/disc oncerting to supporters. Inform this is a common reaction.

Screaming, grunting, or other sounds voiced

Continues to fear she will tear apart Instruct pt to “push through the pain and burning”

Head descends vulva w/ each contraction  perineum becomes extremely thin, anus stretches/protrudes Extension occurs under symphysis pubis, head is born. Shoulders meet underside of symphysis  gentle push  shoulders born and body follows Cardinal Movements: Flexion, Internal Rotation, Extension, Restitution, External Rotation, Expulsion

Stage 3 – the time from the birth of the baby until the completed delivery of the placenta - Placental Separation o Uterus contracts firmly  ↓ surface area  placenta begins to separate o

Separation comes w/ bleeding  hematoma between placental tissue & remaining decidua

o

Hematoma speeds up the process & membranes are last to separate

o

Signs of separation appear 5 min after birth, or up to 30 min. 2 of 12

NUR 1421 Signs: a globular shaped uterus, a rise of the fundus in abdomen, a sudden gush or trickle of blood, and further protrusion of umbilical cord out of vagina Placental Delivery o When signs appear  women may bear down to aid in placental expulsion o

-

o

If it fails  gentle traction may be applied to the cord while pressure exerted on fundus

o

Placenta considered retained if 30 min have passed since completion of 2nd stage

o

Schultze Mechanism (Shiny Schultze) – placenta separates from inside to outer margins; expelled on fetal (shiny) side Duncan Mechanism (Dirty Duncan) – placental separates from outer margins inward, roll up, & present sideways w/ maternal surface first

o

Stage 4 – the time from 1-4 hours after birth when physiologic readjustments of mother’s body begins - Hemodynamic changes – blood loss ranges from 250-500 mL  moderate drop in systolic/diastolic BP, ↑ pulse pressure, & moderate tachycardia - Uterus remains contracted and is midline of abdomen

-

Fundus is usually midway between symphysis pubis and umbilicus After birth of placenta, cervix is widely spread & thick N/V during transition stops, women may be thirsty/hungry, may experience shaking chill

-

Bladder is hypotonic d/t trauma and/or anesthetics that ↓ sensations  urinary retention

-

2.4 The learner will compare and contrast internal and external fetal assessment and contraction monitoring techniques as they relate to the following: 1. Fetal Assessment: a) Heart rate External - Electronic monitoring of FHR done by using an ultrasound transducer - placed on the maternal abdomen over the fetal back, where FHR is loudest, and held in place w/ an elastic belt - water-soluble gel applied to underside to aid in conduction of heart sounds Advantages: produces continues graphic recordings, can show a baseline, baseline variability, and changes in FHR; it is noninvasive and does not require rupture of membranes or minimal cervical dilation Disadvantages: susceptible to inference from maternal & fetal movement and produce a weak signal, tracing may become sketchy and difficult to interpret - repeating procedure remedies weak signal & tracing

-

-

-

-

Internal Monitoring is done w/ a fetal scalp electrode (FSE) – a fine surgical spiral wire attached to the fetal scalp It is attached to the fetus during a vaginal exam

Advantages: Most precise method b/c it is a direct ECG of the FHR and produces the most accurate tracing, provides instantaneous/continuous recording clearer than external Disadvantages: infections/injuries from internal electrodes and catheters are a small risk; contraindicated in active vaginal bleeding from unkown source or placenta previa, maternal infections (HIV, HERPES, HEP), ↑ risk for early onset group-B strep (GBS) in neonate (decision should be based on risks vs benefits), ↑ risk of ventricular hemorrhage in preterm babies – avoided

2. Uterine Assessment: a) Duration, b) Frequency, c) Strength & d) Resting tone External Internal Done by using a tocodynamometer/tocotransducer - Done by using an intrauterine pressure catheter – pressure monitoring device placed on mom’s (IUPC) – catheter inserted into the uterine cavity abdomen or near fundus and held in place w/ an through the cervical os. elastic belt - Placement in area of fetal small parts, reflects Palpate uterus to locate fundus for placement pressure inside uterine cavity - Pressure changes in uterus  changes relayed Used to assess frequency and duration; it cannot determine intensity through transducer to fetal monitor Palpation must be used to assess intensity - IUPC can measure resting tone and actual amount of intensity When the belt is tight enough the nurse should be - Two types: fluid-filled catheters & solid-tipped able to not the start of a contraction before or at the 3 of 12

NUR 1421 same time mom feels it There is also a beltless toco available Advantages: noninvasive, easy to place, used before/after rupture of membranes; used intermittently to allow ambulation, showering, or use of whirlpool bath; provides permanent/continuous recording of D/F Disadvantage: it is not flawless, does not replace a nurse  routinely palpate intensity/relaxation & compare w/ data from monitor; belt may be uncomfortable, require frequent readjustments w/ position changes; mother may feel inhibited to move so not to disturb belt -

catheters Can only be used after membranes are ruptures and pt has adequate cervical dilation – 2-3+ cm. Advantages: provides near-exact measurements of contraction intensity & uterine resting tone; very accurate timing/frequency of UC; less affected by ↑ maternal BMI; preferred method to avoid tachysystole & uterine rupture in mom w/ hx of C/S attempting vaginal after cesarean & receiving oxytocin; in prolonged labor  assess frequency/strength of UC Disadvantages: invasive; ↑ risk of uterine infection or perforation or trauma; contraindicated in cases when active infections can be transmitted; insertion w/ a lowlying placenta  hemorrhage & non-reassuring fetal status; IUPCs require proper insertion & zeroing procedures

-

2.5 The learner will distinguish the nursing management and plan the appropriate care of the intrapartal family from admission to the completion of the fourth stage of labor considering the following: Physical 1. Leopold’s Maneuver - Determining fetal head position, presentation, & lie; procedure should be done between contractions - Difficult to perform on an obese woman or she who has excessive amount of amniotic fluid, hydramnios - Women should have recently emptied bladder, lie on her back w/ abdomen uncovered - To aid in relaxation  raise shoulders slightly on a pillow & knees drawn up a little First Maneuver: palpate upper abd w/ both hands; determine shape, size, consistency, & mobility; fetal head – firm, hard, round, & moves independently; breech feels softer, symmetrical, has small bony prominences & moves w/ the trunk Second Maneuver: after determining if head/buttocks occupy fundus, locate fetal back. Palpate w/ deep but gentle pressure, using palms  right hand steady while left hand explores RS of uterus, then repeat vise-versa; fetal back should feel firm, smooth & should connect w/ what was found in the fundus w/ a mass in inlet; validate finding by palpating fetal extremities on opposite side Third Maneuver: determine what fetal part is lying above inlet – gently grasp lower portion of abd just above symphysis pubis w/ thumb/fingers of right hand Fourth Maneuver: nurse faces women’s feet to locate cephalic prominence or brow; fingers of both hands moved gently down the sides of uterus toward pubis; cephalic prominence is located on the opposite side of fetal back if the head is well flexed; if fetal head extended  occiput is first prominence felt & is located on the same side as the back. 2. Head to toe physical assessment – page 461 3. Review of systems – page 449 4. Evaluation of labor progress - Category 1 (normal) – low-risk women; monitored w/ intermittent auscultation q30min in 1st stage & q15min in 2nd stage - Category 2 (indeterminate) or 3 (abnormal) – assessed and tracings evaluated q15min in 1st stage & q5min in 2nd stage - Periodic documentation w/ each evaluation - Intermittent auscultation for low-risk women receiving oxytocin q15min and after an ↑ oxytocin - When EFM used review data at least q30min - Intermittent monitoring – hands on assessment including auscultation of FHR & palpation of UC 4 of 12

NUR 1421 5. Vaginal Exam – reveals fetus presentation, position, station, degree of flexion of fetal head, & any swelling present on fetal scalp (caput succedaneum) 6. Membrane status 7. Fetal assessment 8. Uterine assessment 9. Using Friedman graph of labor patterns: a) Mean, b) Prolonged Latent Phase, c) Protracted Labor & d) Secondary Arrest of Labor Psychosocial 1. Responses to stages and phases of labor 2. Support system 3. Preparation for childbirth Cultural 1. Labor rituals 2.6 The learner will interpret and provide appropriate nursing interventions for women experiencing periodic and episodic fetal heart rate changes as it relates to following: 1. Fetal heart rate: a) Baseline – determined by approximating the average FHR during a 10-min period, rounded to increments of 5 bpm - Normal BL: 110-160 bpm - As gestational age ↑, FHR ↓ - ↓ an average 16 bpm between 16 weeks and term - Slowing of FHR occurs as PNS matures and exerts control over fetal heart activity b) Tachycardia - BL FHR >160 bpm for at least a 10-min period - Causes may be idiopathic, maternal, fetal, or a combination of M/F - Tachy in the presence of good variability  not a sign of fetal distress - Maternal causes: fever, dehydration, anxiety, hyperthyroidism, supraventricular tachycardia, betasympathomimetic or sympathetic drugs (ritodrine, terbutaline, atropine, isoxsuprine) - Fetal causes: early fetal hypoxia, asphyxia, fetal anemia, infection, prematurity, prolonged fetal stimulation, fetal heart failure - Considered a nonreassuring sign if there are FHR patterns – late decel, severe vari decel, or ↓ or absent variability - Is d/t maternal fever  Tx: antipyretics, cooling measures, antibiotics - Fetal arrhythmias/dysrhythmias need to be ruled out - Notify pediatrician, tachy  HF in newborn - Tx for tachy is Tx of underlying cause c) Bradycardia - BL FHR 25 bpm 3. Periodic and episodic changes: periodic is d/t uterine contractions & episodic are not d/t UCs a) Variable Decelerations - Have a U or V shape & associated w/ cord compression - Abrupt onset and return to normal abruptly also - Vary in intensity/duration & usually correlate to UCs - Not concerning unless decel is...