OB Test 2 NUR4160 - Lecture notes OB Test 2 lectures PDF

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Labor and Birth Process -Chapter 13 Factors Influencing the Onset of Labor Uterine stretch ● Twins tend to be preterm Progesterone withdrawal ● Progesterone and estrogen levels ↓ → oxytocin levels ↑ → contractions Increased oxytocin sensitivity ● Avois sex or breeast stimulation pid Increased releas...

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Labor and Birth Process -Chapter 13 Factors Influencing the Onset of Labor Uterine stretch ● Twins tend to be preterm Progesterone withdrawal ●

Progesterone and estrogen levels ↓ → oxytocin levels ↑ → contractions

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Increased oxytocin sensitivity ● Avois sex or breeast stimulation pid Increased release of prostaglandins ● Prostaglandins help with the relaxation and preparation for L&D Premonitory Signs of Labor Cervical changes (cervical softening, possible cervical dilation) ● Cervical effacement: cervix thins ● Cervical dilation: cervix begins opening Lightening ● Fetal presenting part begins to descend into the true pelvis (abdomen starts falling) Increased energy level (nesting) Bloody show ● Mucus plug comes out with blood (pink-tinged) Braxton Hicks contractions ● Not true because crvux does not dilate and are less frequent Spontaneous rupture of membranes ● Loss of amniotic fluid prior to onset of labor True Versus False Labor -

Contraction timing → longer

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Contraction strength → stronger

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Contraction discomfort ● Starts in the back and radiates towards abdomen (true) ● Abdominal pain that does not start in the back (false) ● Backache that does not radiate to abdomen (false) Change in contraction activity ● If you're still 3cm after 4hrs of being 3cm, then you are in false labor Stay or go? Critical Factors Affecting Labor and Birth (“Five Ps”) Passageway (birth canal: pelvis and soft tissues) ● Younger mothers may have more pliable pubic symphysis Passenger (fetus and placenta) ● Fetal lie: the relationship of the fetal spine with the maternal spine (oblique, transverse, longitudinal) ● Fetal attitude: relationship of the fetal limbs to the body Powers (contractions) ● Uterine contractions and strength Position (maternal) ● Occiput: back of the head ○ When babies coming head down ● Mentum: chin ○ When babies coming face down ● Sacrum: butt ○ When babies coming butt down Psychological response

Five Additional Factors Affecting the Labor Process Philosophy (low tech, high touch) Partners (support caregivers) Patience (natural timing) ● Premature pushing can lead to cervix getting swollen Patient preparation (childbirth knowledge base) Pain control (comfort measures) Passageway: Bony Pelvis Linea terminalis: division of false and true pelvis True pelvis (below linea terminalis) ● Inlet: allows entrance to true pelvis ● Midpelvis: space between inlet and outlet ● Outlet (pelvic measurements): bound by the ischial tuberosity, the lower rim of symphysis pubis, and top of coccyx False pelvis (above linea terminalis) ● Upper flared parts of two iliac bones and concavities ● Wings of base of sacrum Passageway: Bony Pelvis (cont.) Pelvic shape ● Gynecoid: favorable for vaginal delivery ● Android: male shaped, not favorable ● Anthropoid: usually adequate ● Platypelloid: not favorable Passageway: Soft Tissues Cervix: Thins through effacement to allow presenting part to descend into vagina Pelvic floor muscles: helps fetus rotate anteriorly as it passes through birth canal Vagina Passenger Fetal skull Fetal attitude Fetal lie Fetal presentation ● Area where it presents in the lower segment Fetal position Fetal station/Fetal engagement ● Head is engaged at station zero: head at ischial spine Passenger: Fetal Skull Largest and least compressible structure Sutures: allow for overlapping and changes in shape (molding) ● Help identify position of fetal head Fontanels: intersections of sutures; help in identifying position of fetal head and in molding ● Anterior: diamond ● Posterior: triangle Diameters: occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal Passenger: Fetal Presentation Cephalic (vertex) ● Head first ○ Military ○ Brow ○ Face

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Breech ● Frank: buttocks presents first with both legs extended to face ● Full or complete: fetus sits crossed-legged above the cervix ● Footling or incomplete: one or both legs are presenting Shoulder Passenger: Fetal Position the relationship of a given point on the presenting part of the fetus to a designated point of the maternal pelvis Landmarks: ● Occipital bone (O): vertex presentation ● Chin (mentum [M]): face presentation ● Buttocks (sacrum [S]): breech presentation ● Scapula (acromion process [A]): shoulder presentation Three-letter abbreviation for identification: ROA, ROT, ROP & LOA, LOT, LOP Passenger: Fetal Station The relationship of the presenting part to the level of the maternal pelvis ischial spine ● Measured in CM and has (-) or (+)- above or below ischial spine ○ Zero station: leveled at ischial spine Passenger: Fetal Engagement Signifies entrance of the largest diameter of the fetal presenting part (usually head) into the smallest diameter of the maternal pelvis Presenting part reaching 0 station Floating: no engagement; presenting part freely movable about pelvic inlet Cardinal Movements of Labor Positional changes fetus goes through the passageway ● Engagement: occurs when the greatest transverse diameter of the head in vertex passes through the pelvic inlet -Usually 0 station Descent: downward movement of fetal head until it is within pelvic inlet Flexion: vertex meets resistance from the cervix, the walls of the pelvis, or the pelvic floor Internal rotation: after engagement as head descends to lower portion of the head meets resistance from one side of the pelvic floor, head rotates 45 degrees anteriorly to the midline under the symphysis Extension: extension occurs after internal rotation is complete, head emerges through extension under symphysis pubis along with shoulders ● Anterior fontanel, brow, nose, mouth, and chin are born External rotation: head is born and free of resistance, it untwists, causing occiput to move about 45 degrees back to its original left or right position ● External rotation of fetal head allows shoulders to rotate internally to fit the maternal pelvis Expulsion: rest of the body occurs more smoothly after birth of the head and the anterior and posterior shoulders

Mechanisms of labor. A and B, Descent. C, Internal rotation. D, Extension. E, External rotation

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Uterine contractions (primary stimulus) Intra-abdominal pressure from mother pushing and bearing down Contractions: involuntary: thin and dilate cervix Three parameters ● Frequency: how often ● Duration: how long ● Intensity: how strong Characteristics of uterine contractions

Psychological Response Factors influencing a positive birth experience ● Clear information on procedures ● Support, not being alone ● Sense of mastery, self-confidence ● Trust in staff caring for her ● Positive reaction to the pregnancy ● Personal control over breathing ● Preparation for the childbirth experience Physiologic Responses to Labor: Maternal Increased heart rate, cardiac output, blood pressure (during contractions) Increased white blood cell count Increased respiratory rate and oxygen consumption Decreased gastric motility and food absorption Decreased gastric emptying and gastric pH Physiologic Responses to Labor: Maternal (cont.) Slight temperature elevation Muscle aches/cramps Increased BMR

Decreased blood glucose levels Physiologic Responses to Labor: Fetal Periodic FHR accelerations and slight decelerations Decrease in circulation and perfusion Increase in arterial carbon dioxide pressure Decrease in fetal breathing movements Decrease in fetal oxygen pressure; decrease in partial pressure of oxygen Stages of Labor

Stages of Labor First stage true labor to complete cervical dilation (10 cm) ● Longest of all stages ● Two phases ○ Latent phase ○ Active phase ● Nulliparous versus multiparous ● Maternal behaviors Second stage: cervix 10 cm dilated to birth of baby Effacement of the cervix in the primigravida. A, Beginning of labor. There is no cervical effacement or dilation. The fetal head is cushioned by amniotic fluid.

Effacement of the cervix in the primigravida. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head

Effacement of the cervix in the primigravida. C, Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.

Effacement of the cervix in the primigravida. D, Complete effacement and dilatation

Stages of Labor (cont.) Third stage: birth of infant to placental separation ● Placental separation ● Placental expulsion Fourth stage: 1-4 hours following delivery ● Monitor for hemorrhage, bladder distention, and venous thrombosis Signs of Placental Separation -

The uterus rises upward The umbilical cord lengthens A sudden trickle of blood is released from the vaginal opening The uterus changes its shape to globular ●

If a lobe is left behind → risk for postpartum hemorrhage

Placental separation and expulsion- A: Schultze mechanism. Placental separation and expulsion- B: Duncan mechanism.

Factors Influencing Pain During Labor and Birth Physiologic Spiritual Psychosocial Cultural Environmental Nursing management during normal labor and birth & labor and birth at risk Chapters: 14, 21 Chapter 14 Key Terms Related to Fetal Heart Rate Accelerations Baseline fetal heart rate Baseline variability Deceleration Electronic fetal monitoring Periodic baseline changes 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) ● Rupture of membranes

● Uterine contractions (see Figure 14.2) ● Leopold’s maneuvers (see Nursing Procedure 14.1) Leopold’s maneuvers for determining fetal position and presentation First maneuver: what fetal part (head or buttocks) is located in the fundus? Second maneuver: on which maternal side is the fetal back located? Third maneuver: 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. Fourth maneuver: 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. Fetal Assessment During Labor and Birth Amniotic fluid analysis Fetal heart rate monitoring ● Handheld vs. electronic; intermittent vs. continuous; external vs. internal ○ Intermittent monitoring allows women to be mobile during first stage of labor Fetal heart rate patterns ● Baseline, baseline variability, periodic changes (see Table 14.1) Other assessment methods ● 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 ● To provide information about fetal oxygenation and prevent fetal injury from impaired oxygenation ● To detect fetal heart rate changes early before they are prolonged and profound Location of FHR in relation to the more commonly seen fetal positions.

Criteria for Using Continuous Internal Monitoring of the FHR 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). 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 every 30 minutes during active labor for low-risk women and every 15 minutes for high-risk women During second stage of labor intermittent auscultation every 15 minutes for low-risk women and every 5 minutes for high-risk women 4 Categories of Baseline Variability Normal FHR: 120-160 Absent: fluctuation range undetectable

Minimal: fluctuation range observed at 25 beats per minute Types and characteristics of early, late, and variable decelerations.

Variable declaration Cord compression/ category 2 or 3 Early deceleration Head compression; no intervention required Accelerated Okay Late decelerations Placenta- some degree of fetal hypoxia category Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes ● Rate usually drops to less than 90 bpm ● Factors associated: including prolonged cord compression, abruptio placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, maternal seizures, regional anesthesia, or uterine rupture

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 Non Pharmacological Measures for Pain Management Continuous labor support Hydrotherapy

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Ambulation and position changes (see Table 14.2, Figure 14.9) ● Leaning forward, sitting in a chair, birthing ball Acupuncture and acupressure Attention focusing and imagery Therapeutic touch and massage ● Effleurage: light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions Breathing techniques (e.g., patterned-paced breathing) Pharmacologic Measures Systemic analgesia Regional or local anesthesia Neuraxial analgesia/anesthesia techniques: 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) ●

Opioids (butorphanol, nalbuphine, meperidine, fentanyl): ↓FHR & RR → birth should occur within 1 hour or after 4 hours of administration to prevent fetus from receiving peak concentration

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Ataractics (hydroxyzine, promethazine): Neither affect the progress of labor but can ↓FHR

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Benzodiazepines (diazepam, midazolam): CNS depression

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dilation >5 cm Fetal distress secondary to maternal hypotension → women avoids a supine position after catheter

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has been placed ● Prolongs labor due to no sensation felt and spinal headache Combined spinal-epidural block (“walking epidural”)

● Rapid onset of relief, allows womens motor function to remain active (“walking epidural”) ● Second stage of labor Patient-controlled epidural Local infiltration (usually for episiotomy or laceration repair): injection of a local anesthetic such as lidocaine Pudendal block (usually for 2nd stage, episiotomy, or operative vaginal birth) ● Administered 15 minutes before to ensure full effect & lasts for 1 hour 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 Ensure patient is NPO, patent IV line, place a wedge underneath woman's right hip to prevent vena cava compression in supine position First Stage of Labor: Phone Assessment Estimated date of birth Fetal movement; frequency in past few days Other premonitory signs of labor experienced Parity, gravida, and previous childbirth experiences Time frame in previous labors Characteristics of contractions Bloody show and membrane status (whether ruptured or intact) Presence of supportive adult in household or if she is alone Nursing Care During First Stage of Labor General measures ● Obtain admission history ● Check results of routine laboratory tests and any special tests ● Ask about childbirth plan ● Complete a physical assessment Initial contact either by phone or in person First Stage of Labor: 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) ● Fundal height measurement ● Uterine activity, including contraction frequency, duration, and intensity ● Status of membranes (intact or ruptured) ● Cervical dilatation and degree of effacement ● Fetal heart rate, position, station ● Pain level First Stage of Labor: Admission Assessment (cont’d.) Fetal assessment Lab studies ● Routine: urinalysis, CBC ● Syphilis screening, HbsAg screening, GBS, HIV (with woman’s consent), and possible drug screening if not included in prenatal history

Assessment of psychological status First Stage of Labor: Continuing Assessment Woman’s knowledge, experience, and expectations Vital signs ● VS every hour during latent phase and every 30 minutes during active ○ Temperature is taken every 4 hours during first stage and every 2 hours after membrane have ruptured Vaginal examinations Uterine contractions ● Assessed every 30-60 minutes during latent phase and every 15-30 minutes during active Pain level Coping ability FHR Amniotic fluid (see Table 14.3) Nursing Management: Second Stage Assessment ● Typical signs of 2nd stage ○ Increased irritability, spontaneous rupture of membranes, increased blood-tinged show, low grunting sounds from woman, rectal and perineal pressure, involuntary bearing-down efforts ● Contraction frequency, duration, intensity ● Maternal vital signs every 5-15 minutes ● Fetal response to labor via FHR ● Amniotic fluid with rupture of membranes ● Coping status of woman and partner Assessing fetal position and station. Top: The fetal head progressing through the pelvis. Bottom: The changes the nurse will detect on palpation of the occiput through the cervix while doing a vaginal examination.

Nursing Management: Second Stage Interventions ● Supporting woman & partner in active decision making ● Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced ● Providing instructions, assistance, pain relief ● Using maternal positions to enhance descent and reduce pain ● Preparing for assisting with delivery Nursing Management: Second Stage (cont’d.) Interventions with birth ● Cleansing of perineal area and vulva ● Assisting with birth, suctioning of newborn, and umbilical cord clamping ● Providing immediate care of newborn

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Drying: warmth and stimulation

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Apgar score: 1. heart rate (absent, slow, or fast) 2. respiratory effort (absent, weak cry, or good strong yell) 3. muscle tone (limp, or lively and active) 4. response to irritation stimulus 5. color—that evaluate a newborn’s cardiorespiratory adaptation after birth ○ Identification Nursing Management: Third Stage Assessment ● Placental separation; placenta and fetal membranes examination; perineal trauma; episiotomy; lacerations Interventions ● 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 Nursing Management: Fourth Stage Assessment ● Vital signs, fundus, perineal area, comfort level, lochia, bladder status ○ Decrease in BP: hemorrhage and increase: preeclampsia ○ Normal RR: 16-24 ○ Assess fundal height, position, and firmness every 15 minutes during first hour of birth ■ Fundus needs to remain firm to prevent excess postpartum bleeding (feels like size and shape of grapefruit) ■ If it is not firm (boggy): massage until its firm Interventions ● Support and information ● Fundal checks; perineal care and hygiene ● Bladder status and voiding ● Comfort measures ● Parent–newborn attachment ● Teaching Chapter 21: Nursing Management of Labor and Birth at Risk Risk Factors for Dystocia Epidural analgesia/excess...