Labor from Old\'s maternal newborn nursing PDF

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Labor concepts from chapter 19 from Old's Maternal Newborn Nursing 11th edition ...

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LABOR CH. 19 Theories why labor start

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What are hormones during labor?

Progesterone - Estrogen Ratios increase estrogen Oxytocin Stimulation- PPG makes uterus contract Prostaglandins- make uterus contract Fetal Cortisol level increase- baby increases at the end of term Uterine Distention- cervical pressure

 Estrogen stimulates uterine muscle contractions to soften, stretch, and thin the cervix  Progesterone relaxes uterine smooth muscle by interfering with the conduction of impulses to cells  Release of oxytocin may have a physiologic

role to induce labor  Growing fetus distends uterus sufficiently and presenting part puts sufficient pressure on cervix to initiate labor  Fetal cortisol (produced by fetal adrenals)

level increase  Prostaglandins successful induction of labor after vaginal application of prostaglandin E (alprostadil) behind the fornix of the cervix

When is someone When a woman has contractions that result in in labor? cervical change What are the  Passage- pelvis  Passenger- fetus and placenta four P’s of birth  Powers- forces of labor process?  Psyche

LABOR CH. 19 Where are the true and false pelvis?

What is the true pelvis?

What are the different parts of a true pelvis?

What is the false pelvis?

 The critical factor for the passageway because the fetus must go through there during vaginal birth  Lies below the pelvic brim  Made up of sacrum, coccyx, and innominate bones  Size and type is important  Inlet- upper border part of the true pelvis, starts at pelvic brim  Mid pelvis- curved canal with a longer posterior than anterior wall  Outlet- lower border of the true pelvis The portion above the pelvic brim and serves to support weight of the enlarged pregnant uterus and direct the fetal to the true pelvis

LABOR CH. 19 What are the different types of pelvises?

what are the implications of pelvic type?

Why is a vaginal exam done?

What is a diagonal

 Gynecoid- inlet rounded and adequate, midpelvis adequate with parallel sides, outlet adequate, best for vaginal birth (front and back narrow, adequate outlet)  Android- inlet heart shape and short posterior sagittal diameter, mid-pelvis reduced, outlet reduced, not best for vaginal birth can cause slow descent into pelvis with fetal entering in transverse (wide back, narrow front, back labor, facing up, longer birth cause baby rotate to the back)  anthropoid- inlet oval and long anteroposterior diameter, mid-pelvis adequate, outlet adequate, best for vaginal birth (front narrow, back wide, baby does not rotate)  platypelloid- inlet oval and long transverse diameter, mid-pelvis reduced, outlet inadequate, not best for vaginal birth cause fetal head to come in transverse position, hard to go down mid-pelvis, delay of outlet progress  See if they can stay from vagina and touch coccyx  If they can pelvis is narrow from front to back and dilation, effacement, station, and presentation  2 fingers in subpubic angle and if they are beside each other then, adequate outlet  a fist and put it between butt and if it can accommodate the fist = adequate outlet Palpating the sacral promontory with the tip of the middle finger and using the other hand to mark the

LABOR CH. 19 conjugate? What is cervical dilation?

What is effacement?

What is station?

inferior margin  For the vagina to distend  The cervix starts as firm as the tip of the nose  From 0-10  Primigravida- 1 cm per hr  Multigravida- 1.2- 1.5 cm per hr  Grand multigravida

Thinner and shorter Cervix 2 in long and get shorter and shorter Gets as thin as the pinna or sheet of paper As soft as mucus membrane The head in relation to the ischial spine Above ischial spine= (-) the greater the number the higher the baby is  At the ischial spine = 0 or engagement  Below the ischial spine = (+) the greater the number, the lower the baby is      

LABOR CH. 19 What can affect the birth canal?

What are the three parts of the skull?

what is molding? What are sutures?

What are the different types of sutures?

What are fontanelles? What are the different type of fontanelles?

What is the mentum? What is the sinciput? What is vernix? What is occiput?

Deformities of the spine Pelvic trauma- accident, fractures Pelvic infections Cervical trauma- adhesions, scarring The face- bones are fused and fixed The base/cranium- bones are fused and fixed The vault of the cranium/ roof- 2 temporal bones, each with a sphenoid and ethmoid bone, these bones are not fused The cranial bones overlapping under pressure of labor and pelvis Membranous joints that unite the cranial bones       

 Frontal suture- between the two frontal bones  Sagittal suture- between the parietal bones, divides skull in L and R  Coronal suture- between frontal and parietal bones, L and R  Lambdoidal suture- right above occipital bone, across Intersection of cranial sutures forming irregular space enclosed by a membrane  Anterior- diamond shape, 2-3 cm, junction of sagittal, coronal, and anterior junction, closes after 18 months  Posterior- triangle shape, 1-2 cm, intersection of sagittal and lambdoidal suture, closes after 2-3 months Fetal chin Anterior brow area to anterior fontanelle Area between anterior to posterior fontanelle Area under the posterior fontanelle, at the occipital bone

LABOR CH. 19 What is fetal attitude? What is the normal attitude? What can changes of attitude cause? What is militant?

Relation of the fetal body parts to one another and posture of baby General flexion- where the head is flexed so that the chin is on the chest, arms crossed over chest and legs flexed at the knees at the stomach The fetal to cause a larger diameter of the head to the mother pelvis causing longer, hard labor

where the head is NOT flexed, arms crossed over chest and legs flexed at the knees at the stomach What is fetal lie?  Relationship of the long/cephalocaudal axis of the fetus to the long/cephalocaudal of the mother  A longitudinal lie is when the cephalocaudal of the fetus is parallel to women spine  A transverse lie is when the cephalocaudal of the fetus spine is at a right angle to the woman spine, associated with a shoulder presentation and can cause complications  Oblique lie is when the cephalocaudal of the fetus is diagonal to women spine What is trial of Trying to labor a pregnant women vaginally, if doesn’t labor? work due to arrest or distress then on to c-section What is VBAC? Vaginal birth after a previous c-section What is TOLAC? trial of labor after cesarean delivery with attempting of having a VBAC What is fetal Determined by fetal lie and is the body part of the presentation? fetus that enters the pelvis first and goes through the birth canal What is the Portion of the fetus that is felt through the cervix presenting part? during vaginal exam What are the Cephalic- head different types of Breech- butt or feet first fetal Shoulder presentation? Breech and shoulder are malpresentations because they cause difficulties What are the  Vertex- the presenting part is occiput, head is types of cephalic completely flexed, small diameter  Sinciput- head somewhat flexed, occipitofrontal presentation? diameter to pelvis, top of head is presenting  Brow- where the head is somewhat extended, arms crossed over chest and legs flexed at the knees at the stomach, delivered by c-section, occipitomental diameter  Face- where the head is fully extended, arms

LABOR CH. 19 crossed over chest and legs flexed at the knees at the stomach, delivered vaginally, submentobregmatic diameter

What are the types of breech presentation?

What is shoulder presentation?

What is fetal position?

 Complete- fetal knees and hips flexed, thighs on abdomen, and claves are on the posterior aspect of the thighs, buttocks and feet are present to the pelvis  Frank- hips flexed, knees extended, butt is present in pelvis  Footling- hips and legs extended, feet is present in pelvis, single footling = 1-foot present, double footling = 2 feet present

Fetus shoulder is present, in transverse lie and the acromion process of the scapula is present

 The relationship of the landmark on the presenting fetal part to the anterior, posterior,

LABOR CH. 19

What are the four imaginary lines? What are the different landmarks?

What are malpositions? What are the vertex positions?

What are the breech positions?

What are face positions?

What are shoulder positions?

or sides/transverse of the maternal pelvis  1. R or L  2. Presenting part  3. presenting part in relation to the maternal pelvis  Left anterior, right anterior, left posterior, right posterior, transverse  R or L of the maternal pelvis  Vertex = occiput  Face presentation = mentum  Breech presentation = sacrum  Shoulder presentation = acromion Leading parts Positions other than occiput anterior because they can cause problems during labor  ROA  ROT  ROP  LOA  LOT  LOP  RSA  RST  RSP  LSA  LST  LSA  RMA  RMT  RMP  LMA  LMT  LMP  R Acromion Dorsal Anterior  RADP  LADA  LADP

LABOR CH. 19 What are the positions?

What is a compound presentation? What is an external cephalic version?

More than one body part coming out at the same time  The OB will try to convert the baby from breech to cephalic position turn in direction of the nose  invasive so need consent, ultrasound to confirm position and to confirm where placenta is  Monitor for 30 minutes prior = fetal admission testing  Saline lock

LABOR CH. 19  Tocolytic medication to stop contractions because more than 5 in one hr = contraction  Rhogam if she is Rh negative  Reactive Non-stress test = test fetal HR at least 15 bpm over baseline lasting 15 seconds, 2 in 20 minutes, used at 32 weeks + What else is a  The placenta, needs to be fundal/ up in the passenger? fundus  Don’t want in the lower uterine segment = low line placenta (high risk, can bleed at any time)  can cover cervix = c- section  partially on the cervix = partial prevail  not in fundus – implantation of the placenta  double set up = set up for a vaginal and csection What are the two Primary forces and secondary forces to deliver the forces? fetus, fetal membrane, and placenta What are primary  Uterine muscular contraction which causes the change of the 1st stage of labor forces?  effacement/thinning and shrinking and dilation of the cervix  Frequency, duration, intensity What are the Use of abdominal muscles, perineal muscles, and secondary pelvic floor muscles to push during the second stage forces? of labor What is tonus?

 Strength of the uterine muscles

Resting pressure in uterus is 8-12 mmHg Peak pressure in the uterus is 35-75 mmHg Only can be measured with internal monitoring Intensity with hand (palpation) Mild = easily indented (nose) Moderate = demonstrates resistance (chin) strong = no indentation with the acme (forehead) The building up of the contraction       

What is increment? What is acme? What is decrement? What is frequency? What is the duration?

The peak of contractions/ strongest part of the contraction The letting up of the contraction The time between the beginning of one contraction and the beginning of the next contraction  Contraction measured from the beginning of the contraction to the completion of the contraction

LABOR CH. 19

What is intensity?

 30-40 seconds to 30-90 seconds  The strength of the uterine contraction during acme/ peak  Estimated by palpating the contraction or an intrauterine pressure catheter attached to an electronic fetal monitor by an OB  Measured in mmHg

What are contractions?

What is bearing down? What are factors in the psychosocial readiness? What are some psyche factors?

How are the contractions in true labor?

How are the contractions in false labor?

After 10 cm dilation, the abdominal muscles contracts as the woman pushes Fear, anxieties, birth fantasies, level of support

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Motivation and preparation for the pregnancy Support Right gender, time rape, incest, Positive Relationship with Mate Previous knowledge/experience Childbirth Education Sense of Mastery, Self-esteem Maintaining Control Trust in caregivers Concerns Preconceived ideas Loss and disappointment values and beliefs Progressive dilation and effacement of the cervix Regular and increase in frequency, duration, intensity, intervals Walking does not help Pain in back then radiate to abdomen ROM and descent of presenting part Do not produce progressive dilations and effacement irregular and does not increase in frequency, duration, and intensity

LABOR CH. 19

What are the stages of labor?

What is the first stage?

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What occurs in the latent phase?

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     What occurs in the active phase?

What occurs in the transitional phase?

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Pain in abdomen Warm bath and walking helps First stage Second stage Third stage Fourth stage From onset of true labor to complete dilation Divided into latent/early phase, active phase, and transitional phase Educate any chance you get Breathing technique- abdominal breathing and relaxation Loss oxygen= acidosis, increase in PaCO2 Onset of regular contractions, cervix begins to dilate but no fetus decent 0-3 cm dilated Frequency of UC’s 5-30 min apart, lasting 20-40 sec Intensity: UC’s begin as mild and progress to moderate Contractions increase in frequency, duration, and intensity but is bearable Mild contraction, woman talkative and anxious, walking Slower for nullipara, faster for multipara Nursing responsibility & intervention: history, labs, consent, IV, enema, prep, I/O, fetal monitoring, comfort Anxiety increases as pain and intensity increases 4-7 cm dilated Fetal descent is progressive Moderate to strong contractions 3-4 min apart lasting 45-60 secs Pain meds, ROM, IV Increase anxiety Fetal descent rate increases Contractions are more frequent, longer duration, and increase intensity 8-10 cm dilation Increase rectal pressure and urge to bear down, and increase in bloody show and ROM Hyperventilation, decrease concentration, sensitive to touch, N/V, belching, crying/yelling, loss of control May be amnesic and sleep in between

LABOR CH. 19

What is the second stage?

What is crowning? What is lightening?

What are the positional changes?

What is mnemonic for the cardinal movements?

contractions  When the cervix is completely dilated and ends with the birth of neonate  Contractions continue and strong  Descent of fetal presenting part continues until it reaches the perineal floor  Sensation to push increases When the fetal head is encircled by the external opening of the vagina and means birth is imminent  The baby dropping lower into the maternal pelvis before delivery  Primigravida – 2 weeks before  Multigravida – onset of labor  Increased pressure of the presenting part  Labor is starting soon  Also known as cardinal movements/mechanisms of labor 1. Engagement- in cephalic presentation, contractions cause baby to go down to the pelvis, head is in ischial spine, and chin is in abdomen 2. Descent- due to 4 forces: pressure of amniotic fluid, pressure of the fundus, abdominal muscle contraction, and extension and straightening of the body 3. Flexion- when the fetal head reaches the soft tissues of the pelvis, chin flexes to chest 4. Internal rotation- head rotating to fit the pelvic cavity diameter 5. Extension- as fetal head passes symphysis pubis, head extends 6. Restitution- shoulders are oblique while head rotates 7. External rotation- shoulders rotate and head turns more to one side 8. Expulsion- the anterior shoulder meets the undersurface of the symphysis pubis and slips under it Every- engagement Darn- descent Fool- flexion In – internal rotation Egypt- extension Really- restitution Eats Raw- external rotation

LABOR CH. 19

What is third stage?

What is the fourth stage?

What are signs or symptoms of labor?

What is the Quantification of Blood Loss (QBL)?

What is Demerol medication?

Eggs- expulsion  Period from birth of baby to delivery of placenta  5-30 minutes  Longer than 30 minutes = retained placenta, remove manually to peel out  D and C= dilation and curettage = scraping of the placenta  If placenta comes out shiny side up = Schultze mechanism/ Shiny Schultze  If placenta comes out maternal side first = Duncan mechanism/ Dirty Duncan  Delivery of the placenta up to 4 hours after birth in which physiologic readjustments of the mother’s body begins  Vital signs every 15 minutes  Massage/palpate fundus, need to be below, at or 1 cm above umbilicus, left or right due to full bladder and higher, consistency of fundus (firm or soft = can cause postpartum hemorrhage)  Fundus needs to be midline, firm, max 1 cm above umbilicus  Cervical changes (for sure)  Bloody Show- mucus plug expelled with blood loss  Rupture of membranes Sudden burst of energy = nesting  Backache  Nausea/Vomiting  Indigestion  Diarrhea Step 1:  Scale is in Kilograms; simply add a zero to the end to get your weight in grams. Step 2:  1 gram = 1ml. Multiplied by 1, it remains the same number. Dry Weight Chart for Activity:  Chuxs: 100 ml  Pad: 100 ml  Gown: 125 ml  Remember to subtract dry weight of each item weighed from the total weight to calculate the QBL o Demerol (mepridine) o Opioid analgesic – Analgesic o 50-100 mg IM or Subq, slow IV push with

LABOR CH. 19

What is Stadol medication?

What is Nubain medication?

contractions o Repeat 1-3 hours o Decrease pain o S/S- seizures, confusion, sedation, hallucinations, respiratory distress, hypotension, constipation, N/V, bradycardia, urinary retention, sweating o Toxic- Respiratory depression, cyanosis, seizures, hypotension o NI- assess type, location of pain, assess BP, pulse, and RR before and during administration, assess bowel functions, explain medication prior, explain analgesic given before pain is severe o Precautions- assist when ambulating, change positions slowly o Contraindication- look at body fat, heart problem use contiously o Stadol (butorphanol) o Opioid analgesic, synthetic o Binds to opioid receptors in the CNS to block pain o Crosses placenta and breast milk o Pain management o 2 mg q 3-4 hrs prn IM Max 4 mg, 1-2 mg slow IV push Max 2 mg o S/S- confusion, sedation, nausea, sweating, cause withdrawal (not given to addicts) o NI- checking admin site, signs of ODrespiratory distress (Narcan) o Teaching- teach about OD potential, teach about withdrawal symptoms o Contraindications o Nubain (nalbuphine HCL) o Opioid analgesic o To decrease Moderate to severe pain o Supplement to balance anesthesia o Prevent opioid itching (small dose) o IM, Subq, slow IV push 10 mg q 3-6 hrs Max 20 mg per dose, o S/S- dizziness, headache, sedation, N/V, sweating o Toxic- respiratory depression

LABOR CH. 19 What are maternal side effects for analgesics? What are the fetal side effects for analgesics? What needs to be done before giving medications? what are relative contraindications ?

What is Narcan medication?

What are the Narcan baby dose? What is regional anesthesia?

What is epidural?

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Respiratory depression N/V Drowsiness, Dizziness

Respiratory depression hypothermia (brown fat metabolism to keep warm)  lethargy Vaginal ex...