OB E2 - Labor and Intrapartum PDF

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OB E2 – Nursing Management during Normal Labor (Ch14)“Now you're not learning to become midwives you're learning basically to take care of the person and call the midwife or call the obstetrician to take care of the baby.”Key Terms Related to Fetal Heart Rate Accelerations  Baseline fetal heart ra...

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OB E2 – Nursing Management during Normal Labor (Ch14) “Now you're not learning to become midwives you're learning basically to take care of the person and call the midwife or call the obstetrician to take care of the baby.”

Key Terms Related to Fetal Heart Rate      

Accelerations Baseline fetal heart rate Baseline variability Deceleration Electronic fetal monitoring Periodic baseline changes o = temporary, recurrent changes made in response to a stimulus such as a contraction

Early deceleration  a decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. (FHR 在 contraction peak 的时候是最低的)

Late Decelerations

 decreases in FHR that occur after the peak of the contraction

Variable Deceleration  abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions.

VEAL

CHOP

Cord compression causes Variable deceleration Head compression causes Early deceleration Acceleration is Okay Placental insufficiency causes Late acceleration

Nursing Management of Laboring Women      

Assessment Comfort measures Emotional support Information and instruction Advocacy Support for the partner

Maternal Assessment During Labor and Birth Maternal status (vital signs, pain, prenatal record review)  Vaginal examination (cervical dilation, effacement, membrane status, fetal descent and presentation) o determine fetal position  because if you put the finger in and feel the posterior fontanelles, you know that’s where the occiput is o determine dilation of the cervix  Rupture of membranes o If membrane is ruptured  reduce the numbers of vaginal examination to avoid ascending infections  Uterine contractions (see Figure 14.2)  Leopold’s maneuvers (next page) o  used externally to determinine fetal position and presentation. o Palpate the abdomen with gentle but deep pressure. o The fetal back (on one side of the abdomen) feels smooth, and the fetal extremities (on the other side) feel knobby.

Each maneuver answers a question: Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) Maneuver 3: What is the presenting part? Maneuver 4: Is the fetal head flexed and engaged in the pelvis? First maneuver - Determine fetal presentation - Facing the woman’s head, place both hands on the abdomen to determine fetal position in the uterine fundus - Feel for the buttocks, which will feel soft and irregular  (indicates vertex presentation) - feel for the head, which will feel hard, smooth, and round  (indicates a breech presentation). Second maneuver: - Determine fetal position - While still facing the woman, move hands down the lateral sides of the abdomen to palpate on which side the back is located (back feels hard and smooth) and which side the limbs are located (nodules with kicking and movement) Third maneuver - To confirm presentation - Place one hand just above the symphysis. Note whether the part palpated feels like the fetal head or the breech and whether it is engaged. - If the presenting part is the head  it will be round, firm, and ballotable - if it is the buttocks  it will feel soft and irregular.

Fourth maneuver: - To determine fetal attitude - Facing the woman’s feet, place both hands on the lower abdomen and move hands gently down the sides of the uterus toward the pubis. Note the cephalic prominence or brow.

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Fetal Assessment During Labor and Birth  Amniotic fluid analysis o should be clear when the membranes rupture o To confirm if they have ruptured  a sample of fluid is taken from the vagina via a nitrazine swab to determine the fluid’s pH.  Vaginal fluid is acidic, while amniotic fluid is alkaline and turns a nitrazine swab blue  Fetal heart rate monitoring  to ensure that the fetus is doing well and that it is properly perfused and is getting enough oxygen. o Handheld vs. electronic o intermittent vs. continuous o external vs. internal  Fetal heart rate patterns o Baseline, baseline variability, periodic changes (see Table 14.1)  Other assessment methods o Fetal scalp sampling, pulse oximetry, stimulation

Continuous Electronic Fetal Monitoring  Uses a machine to produce a continuous tracing of the FHR  Produce a graphic record of the FHR pattern  Primary objective o To provide information about fetal oxygenation and prevent fetal injury from impaired oxygenation o To detect fetal heart rate changes early before they are prolonged and profound Woman in labor with external monitor applied

Location of FHR in relation to the more commonly seen fetal positions The fetal heart is heard best between the scapula of the back. Therefore, where you feel the back is where you are going to put the back - If fetus presentation is breech  you will place the scope above the umbilicus of the mother - If the fetus presentation is head down  you will hear the FHR below the umbilicus

Criteria for Using Continuous Internal Monitoring of the FHR In order to put the monitor in   Ruptured membranes  Cervical dilation of at least 2 cm  Present fetal part low enough to allow placement of the scalp electrode  Skilled practitioner available to insert spiral electrode (ICI, 2011).

**(possible SELECT ALL question) **

Guidelines for Assessing Fetal Heart Rate  Initial 10- to 20-minute continuous FHR assessment on entry into labor/birth area  Completion of a prenatal and labor risk assessment on all clients  Intermittent auscultation o every 30 minutes during active labor for low-risk women o every 15 minutes for high-risk women  During second stage of labor o intermittent auscultation every 15 minutes for low-risk women o every 5 minutes for high-risk women  just put on continuous monitor

4 Categories of Baseline Variability Baseline variability = irregular fluctuations in the baseline FHR  Absent: fluctuation range undetectable  Minimal: fluctuation range observed at 25 beats per minute

Types and characteristics of early, late, and variable decelerations.

 Early deceleration (When the uterine contraction is up, the FHR goes down) is caused by Head compression  Late deceleration (The FHR goes down after/later than the uterine contraction) is caused by placenta insufficiency  Variable deceleration (going down without a pattern) is caused by cord compression

**STUDY THE GRAPHS  WILL BE TESTED

Acceleration is Okay

Determine FHR Patterns Assessing parameters of the FHR include  baseline FHR and variability,  presence of accelerations,  periodic or episodic decelerations,  changes or trends of FHR patterns over time. The nurse must be able to interpret the various parameters to determine FHR pattern  category I = strongly predictive of normal fetal acid–base status at the time of observation o  needs no intervention  category II = not predictive of abnormal fetal acid–base status but does require evaluation o  continued monitoring  category III = predictive of abnormal fetal acid–base status at the time of observation o  requires prompt evaluation and interventions, such as giving maternal oxygen, changing maternal position, discontinuing labor augmentation medication, and/or treating maternal hypotension **SEE Table below

Prolonged deceleration = when it’s going down, it’s going down for a long time, not just a wave

***KNOW THIS!!!

Comfort and Pain Management  Pain as universal experience; intensity highly variable  Mandate for pain assessment in all clients admitted to health care facility  Numerous nonpharmacologic and pharmacologic choices available o Choice is depending on the patient

Nonpharmacological Measures     

Continuous labor support Hydrotherapy Ambulation and position changes (see Table 14.2, Figure 14.9) Acupuncture and acupressure Attention focusing and imagery o Diversion  Therapeutic touch and massage; effleurage  Breathing techniques (e.g., patterned-paced breathing)

Pharmacologic Measures  Systemic analgesia  Regional or local anesthesia  Neuraxial analgesia/anesthesia techniques: o use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space  Shift in pain management: woman as an active participant during labor Systemic Analgesia  Route: typically administered parenterally through existing IV line  Drugs (see Drug Guide 14.1) o Opioids (butorphanol, nalbuphine, meperidine, fentanyl) o Ataractics (hydroxyzine, promethazine) o Benzodiazepines (diazepam, midazolam) Regional Analgesia/Anesthesia

 Epidural block: continuous infusion or intermittent injection; usually started when dilation >5 cm  Combined spinal-epidural block (“walking epidural”)  Patient-controlled epidural  Local infiltration (usually for episiotomy or laceration repair)  Pudendal block (usually for 2nd stage, episiotomy, or operative vaginal birth)  Intrathecal (spinal) analgesia/anesthesia (during labor and cesarean birth) General Anesthesia  Emergency cesarean birth or woman with contraindication to use of regional anesthesia  IV injection, inhalation, or both  Commonly, first thiopental IV to produce unconsciousness  Next, muscle relaxant  Then intubation, followed by administration of nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia

Will discussed in the next PPT If you give patient’s opioid  you must have Narcan (the antidote) on hand ready to use if overdose (ex: respiratory depression) occurs Know the epidural’s side effects

First Stage of Labor Phone Assessment (when patient calls, nurse needs to ask)  Estimated date of birth  Fetal movement; frequency in past few days  Other premonitory signs of labor experienced o Know the signs!!  Parity, gravida, and previous childbirth experiences  Time frame in previous labors  Characteristics of contractions o Know True vs False contraction!!  Bloody show and membrane status (whether ruptured or intact)  Presence of supportive adult in household or if she is alone Nursing Care (now patient has arrived to the hospital)  General measures o Obtain admission history o Check results of routine laboratory tests and any special tests o Ask about childbirth plan o Complete a physical assessment  Initial contact either by phone or in person Admission Assessment  Maternal health history (see Fig. 14.13 & Box 14.2)  Physical assessment (body systems, vital signs, heart and lung sounds, height and weight) o Fundal height measurement o Uterine activity, including contraction frequency, duration, and intensity o Status of membranes (intact or ruptured) o Cervical dilatation and degree of effacement o Fetal heart rate, position, station o Pain level  Fetal assessment  Lab studies

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o Routine: urinalysis, CBC o Syphilis screening, HbsAg screening, GBS, HIV (with woman’s consent), and possible drug screening if not included in prenatal history Assessment of psychological status Woman’s knowledge, experience, and expectations Vital signs Vaginal examinations Uterine contractions Pain level Coping ability FHR Amniotic fluid (see Table 14.3) o Amniotic fluid should be clear when the membrane ruptures; cloudy amniotic fluid may indicate infection o Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes o if you see meconium and baby is coming headwards  baby is in distress; It’s considered normal if the fetus is in breech position

Second Stage of Labor = from the cervix 10 cm dilated  birth of baby Nursing Management – Assessment  Typical signs of 2nd stage  Contraction frequency, duration, intensity  Maternal vital signs  Fetal response to labor via FHR  Amniotic fluid with rupture of membranes  Coping status of woman and partner  Assessing fetal position and station o Top: The fetal head progressing through the pelvis. o Bottom: The changes the nurse will detect on palpation of the occiput through the cervix while doing a vaginal examination; where the fontanelle is = where the back of the baby’s head

Nursing Management – Intervention

 Supporting woman & partner in active decision making  Supporting involuntary bearing-down efforts o Encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced  Providing instructions, assistance, pain relief o Between contractions  tell her to breathe and pant  Using maternal positions to enhance descent and reduce pain o Patient who is sitting up is easier to push because the gravity helps baby to descend  Preparing for assisting with delivery 2 nd stage of labor - Nursing Management – Intervention with Birth  Cleansing of perineal area and vulva  Assisting with birth, suctioning of newborn, and umbilical cord clamping  Providing immediate care of newborn o Drying o Apgar score o Identification (putting on the identification band; All the babies stay in the room with the mothers, and there is no nursery (unless in the NICU))

Third Stage of Labor Assessment  Placental separation (Know the signs!! In the last notes)  placenta and fetal membranes examination  perineal trauma o lacerations o episiotomy = an incision made in the perineum to enlarge the vaginal outlet  inspect the perineum  Applying an ice pack to the perineal area for the first 24 hours  use sitz bath as a comfort measure for her perineum after the first 24 hours Intervention  Instructing to push when separation apparent  giving oxytocin if ordered  assisting woman to comfortable position  providing warmth  applying ice to perineum if episiotomy  explaining assessments to come  monitoring mother’s physical status  recording birthing statistics  documenting birth in birth book

Fourth Stage of Labor Very important because we could lose the mom or the baby at this time Assessment  Vital signs  Fundus o The fundus needs to remain firm to prevent excessive postpartum bleeding o If it’s boggy/soft  gently massage to get it firm o If it’s still not getting firm  contact HCP (order oxytocin to start the contractions to get it firm)  perineal area  comfort level  lochia = vaginal discharge o amount o Assess for bleeding/postpartum hemorrhage  bladder status o assess if she has voided  palpate the bladder for fullness, since many women receiving an epidural block experience limited sensation in the bladder region  Voiding should produce large amounts of urine each time. o A full bladder will displace the uterus to either side of the midline and potentiate uterine hemorrhage secondary to bogginess. Interventions  Support and information  Fundal checks; perineal care and hygiene  Bladder status and voiding  Comfort measures  Parent–newborn attachment  Teaching

OB E2 - Birth& Labor and Birth at risk (Ch21)

Dystocia = abnormal progression of labor Risk factors  Epidural analgesia/excessive analgesia  Multiple gestation  Hydramnios  Maternal exhaustion o Mom is being too tired to push  Ineffective maternal pushing technique  Occiput posterior position o the back of your baby's skull (the occipital bone) is in the back (or posterior) of your pelvis.  Longer first stage of labor  Nulliparity, short maternal stature  Fetal birth weight over 8.8 lb  Shoulder dystocia o Shoulder stuck underneath the pelvis o McRobert maneuver  hyperflexing the mother's legs tightly to her abdomen  get the baby out  Abnormal fetal presentation or position  Fetal anomalies  Maternal age over 35 years  High caffeine intake  Overweight  Gestational age over 41 weeks  Chorioamnionitis = bacterial infection that occurs before or during labor o Could be caused by early rupture of membrane or excessive vaginal examinations  Ineffective uterine contractions  High fetal station at complete cervical dilation

o At risk for cord prolapse Causes of Dystocia  Problems with powers (power has to do with the contractions) o Hypertonic uterine dysfunction  occurs when the uterus never fully relaxes between contractions o Hypotonic uterine dysfunction  occurs during active labor (dilation more than 5 to 6 cm) when contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix. o Protracted disorders  A laboring woman with a slower-than-normal rate of cervical dilation o Arrest disorders  stopped progress o Precipitate labor  abrupt onset of higher-intensity contractions occurring in a shorter period of time = the baby is coming and it’s coming very fast = spontaneous labor  Problems with the passageway o Pelvic contraction o Obstructions in maternal birth canal  Problems with passenger o Occiput posterior position o Breech presentation o Multifetal pregnancy o Macrosomia and CPD o Structural abnormalities  Problems with psyche o Psychological distress

Dystocia Assessment  History of risk factors

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Maternal frame of mind Vital signs Uterine contractions Fetal heart rate, fetal position

Dystocia Management  Promoting labor progress  Providing physical and emotional comfort  Promoting empowerment

Preterm Labor  Regular uterine contractions with cervical effacement and dilation between 20 and 37- weeks’ gestation o Before 20 weeks = abortion o After 37 weeks = full term

 One of most common obstetric complications Therapeutic management  Risk prediction  Tocolytic drugs: o Stops the contraction to keep the baby in as long as possible o there are no clear first-line drugs to manage preterm labor o may prolong pregnancy for 2 to 7 days while steroids can be given for fetal lung maturity o ex: magnesium sulfate  which reduces the muscle’s ability to contract o ex: indomethacin  Antibiotic prophylaxis for women with group B streptococcus to prevent infection  Corticosteroids decrease respiratory distress between 24 and 34 weeks Nursing Assessment  Risk factors  Subtle signs  Contraction pattern (4 contractions every 20 minutes or 8 contractions in 1 hour)  Laboratory and diagnostic testing: o CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length via transvaginal ultrasound, salivary estriol, home uterine activity monitoring

Nursing Management  Tocolytic administration  Client education  Psychological support  If the lady is okay and contractions have stopped  can send her home

Post-term Labor  Pregnancy continuing past end of 42 weeks’ gestation  Unknown etiology  Maternal risks o cesarean birth o dystocia o birth trauma o postpartum hemorrhage o infection  Fetal risks o macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, and cephalopelvic disproportion (CPD) Nursing assessment  estimated date of birth  daily fetal movement counts  nonstress tests twice weekly  amniotic fluid analysis  weekly cervical examinations  client understanding, anxiety and coping ability o reassure the patient Nursing management  fetal surveillance  decision for labor induction  support  education  intrapartal care

Intrauterine Fetal Demise = fetal death that occurs after 20 weeks’ gestation but before birth  Numerous causes

 Devastating effects on family and staff Nursing assessment  Inability to obtain fetal heart sounds  Ultrasound to confirm absence of fetal activity  Labor induction o Patient is not going through C section; they will have to induce labor  the process is even more rough Nursing management  Assistance with grieving process  Referrals for counseling

Umbilical Cord Prolapse  Obstetric emergency = the cord precedes the fetus out (whe...