labor and delivery/ postpartum PDF

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stages of labor and postpartum ...

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5 P’s Power, passageway, passenger, psyche, position Power 1. Primary power a. Present throughout all stages of labor b. Involuntary uterine contractions c. Ferguson reflex- the reflex to push is present when the baby is at +1 engaged 2. Secondary power- voluntary action of pushing  Cervix dilates(drawing up and opening of the cervix) and effaces (thinning) o 10 cm fully dilated end of 1st stage of labor o cervix can no longer be palpated when fully dilated  Contraction phase (Actions) o Increment- the build up of contraction – longest phase o Acme- the peak –shortest phase o Decrement- relaxation  Contraction patterns o Freguency- beginning of 1 contraction to the next o Duration- how long it last o Intensity- firmness of fundus  Mild- tip of nose  Moderate- chin  Strong- forehead Passageway  True pelvis is all the matters o Symphysis pubis and the right and left sacroiliac joints o Become mobile due to increase in estrogen and relaxin o Gynecoid pelvis shape provides the most ideal passageway  The muscles of the pelvic floor help turn and orient the fetus through the cardinal movements of delivery.  Decent of fetus measured in reference to ischial spines o 0 station = engaged o +1 beyond ischial spine o 5+ crowning o negative number not engaged Passenger  Fetal head, Fetal presentation, fetal attitude, fetal lie, fetal position  Fetal head o Molding of skull bones to fit into pelvis  Fetal presentation and attitude o What enter the pelvis 1st of presenting part o 3 primary variations  Cephalic presentation = vertex presentation

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 Sinciput = neck straight  Brow= neck extended (partial)  Facial = neck sharply extended (complete)  Breech= butt or feet  Frank= butt 1st  Complete= legs crossed  Single footling= 1 leg  Double footling = 2 legs  Shoulder= c-section o General flexion is the optimal position for entry into pelvic inlet  Legs flexed at the knees, arms flexed against at the chest, back rounded, the neck flexed with chin on chest o Biparietal of fetal head (side to side)9.25 cm o Subocctipal 11cm Fetal lie o Refers to the relation of the fetal spine to the maternal spine o 2 primary presentation  longitudinal (vertical)  cephalic or breeched  transverse (horizontal)  shoulder presentation Fetal position o Relationship of the presenting part to the maternal pelvis o Fetal position is not the direction in which the fetus is facing but rather the position of the back of the head (occiput) o Described by letters  Left or Right  (O) occiput  (M) mentum for brow or face  (SC) scapula transverse lie  (S) breech position  A anterior  Posterior  T transverse  LOA= most common Psyche o Women state of mind o Anxiety stress and fear can reduce pain tolerance and delay progress of labor o Child birth education courses o On average labor is shorter with continuous support Position o Maternal position o Gravity is great

o Contractions are more acute and productive for a women who is up right and ambulating o Encourage positions she feel more comfortable in (upright or lateral)  Reduced rate of c-sectation  Surgical birth  Reduction of episiotomies and perineal lacerations  Increased sense of comfort and control  Shorted 1st and 2nd stages of labor  Onset of labor o True labor is contractions with dilation of the cervix o Signs of impending labor  Contractions become regular  Bloody show  Lightening  Nesting impulse, surge of energy  GI distress  Weight loss of 1-3 pounds  Cervical changes o Labor is not confirmed unless contractions are continuous and progressive and result in dilation and effacement of the cervix o 411 rule (primagravida)  new contraction every 4 minutes  last for 1 minute  occurring for at least 1 hour o 5-6 minutes of the women lives far away or has given birth  ROM o Suspected ROM w/ contractions- exam o Rom w/out contractions- exam  Blue- amniotic fluid o FHR o Increase for prolapse of the cord if ROM and the baby is not engaged Admissions  Most admissions are in the 1st stage of labor at 3cm dilated  Contractions are regular  ROM  Assessment o Patient interview and physical exam 1st priority  V/C  FHR- 20-30 mins for baseline  Sterile exam  Cervical dilation- posterior cervix is unripe and suggest that labor is unlikely.  Effacement  Fetal station  Presentation

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 Position  Leoplods maneuver Duration and frequency Vaginal discharge Pain assessment Last food and drink Group b streptococcus positive antibiotics are started Birth plan is reviewed Start IV line/ draw blood/collect urine

Stages of labor 1st stage o Longest stage lasting 12 hrs o Begins with the start of regular contractions o 0-10cm o maternal out put increases and pulse increases o V/S every hour o Monitor fetus and contractions every 30 mins if no FHR o Encourage women to void every 2hrs  Latent phase o 0-3 cm o contractions are mild, 30-40 seconds every 30 mins o women can talk through them o feels like menstrual cramps with low back pain o assess every 30-1hr o have patient ambulate o slow paced breathing/ go over pain meds for later o co2 increases o longest stage  Active phase o 3-7 cm o contractions are moderately strong, 30-45 seconds, 3-5 minutes o focused, anxious and restless o ROM more likely to happen during this phase o Lasting 2-5 hours o Epidural given at 5cm o Use non-pharm pain  Transition phase o 8-10 cm o contractions are strong and close together 1-2 mins 40-60 seconds o feel out of control, irritable, uncooperative, exhausted, or dependent o nausea and vomiting o increase in bloody vaginal discharge

o if ROM has not happened OB will  aminotomy  AROM o Pattern paced breathing/ breath deeply during contractions and rest in between/ count breaths Stage 2- fully dilated –child is born  Latency period  Delay pushing until the patient feels the urge to push (ferg reflex 1+) but must be 10cm dilated  Can last as little as 20mins or go on for hours  Cardinal movements- fetus descends and rotates so that they are in an optimal position to mother pelvis for delivery 1. Engagement- fetal head reaches the level of the ischial spine 0 station 2. Descent- moves past 0 during the 1st and 2nd stages feels the ferguson reflex 1+ 3. Flexion- fetal head moves so the chin touches the chest in response of maternal tissue typical in 1st stage. Biparietal diameter widest presenting part 4. Internal rotation- head rotates to align it’s widest part with pelvis a. Pelvic inlet – lateral b. Pelvic outlet- anterior/ posterior 5. Extension- chin comes off chest head is born fetal is occiput anterior position 6. External rotation (restitution)- head rotates again , shoulders move into position to fit through pelvic outley 7. Expulsion- the body of the fest is born  Checks FHR 5-15 mins  Open glottis pushing  Check cord  Episiotomy- midline cut 45 degree angle o 1st degree- through the skin o 2nd degree – muscles of the perineal body o 3rd degree – anal sphincter muscles o 4th degree – involves the anterior rectal wall  If patient feels pain in between her shoulders it’s a c-section. Third stage  when baby is born and ends with the birth of the placenta 5-30 mins  failure of the uterus to contract is known as uterine atony  stimulate oxytocin skin to skin or breastfeeding or administer it  signs of separation o uterus turns more globular o rush of bright red blood o sudden lengthening  active interventions o oxytocin o early cord clamping o gentle traction (pulling)  Active interventions increase

o After pains- more for multipara/baby over 9oz/multi births  Most pronounced during breastfeeding o Use of analgesia o Postpartum vomiting o Return to the hospital due to bleeding  passive delivery o without any interventions  Nursing interventions o v/s q 15mins o skin to skin contact o breast feeding o encourage partner bonding Fourth stage  begins with the birth of the placenta and end 4 hrs after  if parts of the placenta remain attached the uterus will fail to contact completely= increased risk for bleeding  assess fundus for tone, position, and location  with in 1 hr fundus should be at the level of the umbilicus o for each day is could descend 1cm or fingerbreadth  check locia, red lochia called lochia rubra is normal and may include clots o Rubra lochia – fresh blood 3-5 days o Serosa lochia – 10-14 days pink or brown serum o Alba lochia – 2-4 weeks WBC/yellow  If alba after 4 weeks=infection  apply ice packs  assess for bladder function POST PARTUM  after 4hrs to 6 weeks after delivery  involution- shrinkage of the uterus  subinvolution- uterus does not contact or shrink o Hemhorrage o After pains  At 2 weeks it’s a pelvic organ  Scant: less than 1 inch  Light: less than 4 inches  Moderate: 6 inches  Heavy: soaked 1 hr BUBBLEHE  Breast o Tenderness  Uterus o Firm or boggy position  Bladder  Bowel

 Lochia  Episiotomy  Homans sign  Emotional Fetal Monitoring  Find the maternal pulse at the same time as auscultation of FHR  Palpate for an entire contraction cycle o Intensity, duration, frequency  Note resting tone  Auscultate the FHR before, during, and after to get baseline 20-30mins  Obesity can affect monitoring o Internal monitoring allows for contractions to be assessed o Intensity and frequency o Only if membrane have ruptured and cervix has dilated  1st step in evaluating FHR is baseline o 2mins in a 10 min strip  variability over 1min with no a-cells or d-cells o absent- none o minimal- 5bpm or less o moderate- 6-25 bpm o marked- above 25 bpm  Acceleration rise in FHR from the baseline of at least 15 bpm for more than 15 seconds o Reassuring and suggest the fetus is well oxygenated o An a-cell that last of 20 bmp or more for less than 20 seconds that come comes before or after a D-cell is a shoulder  Decelerations is a decrease in FHR below the baseline that lasts for less than 10 mins o Lasting more than 10mins is a change in baseline  Utertine tachysystole 5 or more contractions every 10mins for ½ an hour o Stop oxytocin o Tocolytics to relax uterus and stop contractions  Gloved finger or vibroacoustic stimulation (noninvasive) at the level of the fetal head for 1-5 seconds when the heart rate is at baseline and not incase of bradycardia  Artificially expand the volume of amniotic fluid by instilling ringers lactate or normal saline into amniotic sac IUPC o Gravity flow or pump o Instilled at room temp or warmed o Internal pressure catheter should not exceed 15mm Procedures prior to neuraxial analgesia 1. Assess the pain 2. Assess knowledge level of patient and support person and provide teaching as needed

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Asses baseline vital signs Examine the FHR Have patient void prior to admin Administer an IV fluid Collet blood for laboratory test Perform preprocedure...