UNIT 2 Normal Labor AND Delivery PDF

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2 Key TermsChapter 22  bloody show – pink-tinged mucus secretions resulting from rupture of small capillaries as the cervix effaces and dilates  cardinal movements – the positional changes of the fetus as it moves through the birth canal during labor and birth; the positional changes are descent, ...

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UNIT 2 NORMAL LABOR AND DELIVERY

2.1 Key Terms Chapter 22  bloody show – pink-tinged mucus secretions resulting from rupture of small capillaries as the cervix effaces and dilates  cardinal movements – the positional changes of the fetus as it moves through the birth canal during labor and birth; the positional changes are descent, flexion, internal rotation, extension, restitution, and external rotation; also called mechanisms of labor  cervical dilatation – process in which the cervical os and the cervical canal widen from less than 1 cm to approximately 10 cm, allowing the birth of the fetus  crowning – appearance of the presenting fetal part at the vaginal surface during labor  duration – the time length of each contraction, measured from the beginning of the increment to the completion of the decrement  effacement – thinning and shortening of the cervix that occurs late in pregnancy or during labor  engagement – the entrance of the fetal presenting part into the superior pelvic strait and the beginning of the descent through the pelvic canal  fetal attitude – relationship of the fetal part to one another; normal fetal attitude is one of moderate flexion of the arms onto the chest and flexion of the legs onto the abdomen  fetal lie – relationship of the cephalocaudal axis (spinal column) of the fetus to the cephalocaudal axis (spinal column) of the woman; the fetus may be in a longitudinal or transverse lie  fetal position – relationship of the landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis  fetal presentation – the fetal body part that enters the maternal pelvis first; the three possible presentations are cephalic, shoulder, and breech  fontanelle – in the fetus, an unossified space, or soft spot, consisting of a strong band of connective tissue lying between the cranial bones of the skull  frequency – the time between the beginning of one contraction and the beginning of the next contraction  intensity – the strength of a uterine contraction during acme (highest point/most pressure)  lightening – moving of the fetus and uterus downward into the pelvic cavity

UNIT 2 NORMAL LABOR AND DELIVERY  malpresentation – a presentation of the fetus into the birth canal that is not “normal”; that is, brow, face, shoulder, or breech presentation  molding – shaping of the fetal head by overlapping of the cranial bones to facilitate movement through the birth canal during labor  presenting part – the fetal part present in or on the cervical os  rupture of membranes (ROM) – rupture may be PROM (premature), SROM (spontaneous), or AROM (artificial); some clinicians may use the abbreviation RBOW (ruptured bag of waters)  spontaneous rupture of membranes (SROM) – the breaking of the “water” or membranes marked by the expulsion of amniotic fluid from the vagina  station – relationship of the presenting fetal part to an imaginary line drawn between the pelvic ischial spines  suture – fibrous connection of opposed joint surfaces, as in the skull Chapter 23  accelerations – periodic increases in the baseline fetal heart rate  baseline fetal heart rate (BL FHR) – the average fetal heart rate observed during a 10 minute period of monitoring  baseline variability (BL VAR) – changes in the fetal heart rate that result from the interplay between the sympathetic and the parasympathetic nervous systems  decelerations – periodic decreases in the baseline fetal heart rate  early decelerations – periodic changes in fetal heart rate pattern caused by head compression; deceleration has a uniform appearance and early onset in relation to maternal contraction  electronic fetal monitoring (EFM) – a method of placing a fetal monitor on the fetus in order to obtain a continuous tracing of the FHR, which allows many characteristics of the fetal heart rate to be observed and evaluated  fetal bradycardia – a fetal heart rate less than 120 beats per minute during a 10 minute period of continuous monitoring  fetal tachycardia – a fetal heart rate of 160 beats per minute or more during a 10 minute period of continuous monitoring  intrauterine pressure catheter (IUPC) – a catheter that can be placed through the cervix into the uterus to measure uterine pressure during labor; some types of catheters may be inserted for the purpose of infusing warmed saline to add additional intrauterine fluid when oligohydramnios is present  late decelerations – symmetrical decreases in fetal heart rate beginning at or after the peak of the contraction and returning to baseline only after the contraction has ended, indicating possible uteroplacental insufficiency and potential that the fetus is not receiving adequate oxygenation  Leopold’s maneuvers – a series of four maneuvers designed to provide a systematic approach whereby the examiner may determine fetal presentation and position  palpation – the technique of assessing a uterine contraction by touch  prolonged decelerations – decelerations in which the FHR decreases from the baseline for 2 to 10 minutes  scalp stimulation – a test used during labor to assess fetal well-being by pressing a fingertip on the fetal scalp; a fetus not under excessive stress will respond to the digital stimulation with heart rate accelerations  variable decelerations – periodic changes in fetal heart rate caused by umbilical cord compression; decelerations vary in onset, occurrence, and waveform Chapter 24  Apgar score – a scoring system used to evaluate newborns at 1 minute and 5 minutes after birth; the total score is achieved by assessing five signs: heart rate, respiratory effort, muscle tone, reflex irritability, and color; each of the signs is assigned a score of 0, 1, or 2; the highest possible score is 10

UNIT 2 NORMAL LABOR AND DELIVERY  hyperventilation – rapid breathing that occurs over a prolonged period of time resulting in an imbalance of oxygen and carbon dioxide that can result in tingling or numbness in the tip of nose, lips, fingers, or toes; dizziness; spots before the eyes; or spasms of the hands or feet (carpal-pedal spasms)  precipitious birth – a birth in which no physician is in attendance Chapter 25  epidural block – regional anesthesia effective through the first and second stages of labor  general anesthesia – a state of induced unconsciousness that may be achieved through intravenous injection, inhalation of anesthetic agents, or a combination of both methods  local anesthesia – injection of an anesthetic agent into the subcutaneous tissue in a fanlike pattern  pudendal block – injection of an anesthetizing agent at the pudendal nerve to produce numbness of the external genitals and the lower one third of the vagina to facilitate childbirth and permit episiotomy if necessary  regional anesthesia – the temporary and reversible loss of sensation produced by injecting an anesthetic agent (called a local anesthetic) into an area that will bring the agent into direct contact with nervous tissue  Systemic  regional anesthesia – injection of local anesthetic agents so that they come into direct contact with nervous tissue  spinal block – injection of a local anesthetic agent directly into the spinal fluid in the spinal canal to provide anesthesia for vaginal and cesarean births Chapter 26  amnioinfusion (AI) – procedure used to infuse a sterile fluid (such as normal saline) through an intrauterine catheter into the uterus in an attempt to increase the fluid around the umbilical cord to decrease or prevent cord compression during labor contractions; also used to dilute thick meconium-stained amniotic fluid  amniotomy – the artificial rupturing of the amniotic membrane  cervical ripening – softening of the cervix; occurs normally as a physiologic process before labor or is stimulated to occur through the process of induction of labor  Cesarean birth – birth of fetus accomplished by performing a surgical incision through the maternal abdomen and uterus  episiotomy – incision of the perineum to facilitate birth and to avoid laceration of the perineum  external cephalic version (ECV) – procedure involving external manipulation of the maternal abdomen to change the presentation of the fetus from breech to cephalic  foreceps-assisted birth – a birth in which a set of instruments, known as forceps, are applied to the presenting part of the fetus to provide traction or to enable the fetal head to be rotated to an occiput-anterior position; also known as instrumental delivery, operative delivery,or operative vaginal delivery  labor augmentation – the stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus  labor induction – the stimulation of uterine contractions before the spontaneous onset of labor, with or without ruptured fetal membranes, for the purpose of accomplishing birth  podalic version – type of version used to turn a second twin during a vaginal birth; internal version  vacuum extraction – an obstetric procedure used to assist in the birth of a fetus by applying suction to the fetal head with a soft suction cup attached to a suction bottle (pump) by tubing and placing the device against the occiput of the fetal head  vaginal birth after Cesarean (VBAC) – practice of permitting a trial of labor and possible vaginal birth for women following a previous cesarean birth for nonrecurring causes such as fetal distress or placenta previa

UNIT 2 NORMAL LABOR AND DELIVERY 2.2 Patient Responses and Treatments During the 4 Stages of Labor Maternal physiologic responses  myometrial activity o uterus divides into two portions  upper portion (contractile segment) becomes thicker as labor advances, causes effacement  lower portion (lower uterine segment and cervix) is passive and expands/thins out  musculature changes in the pelvic floor o muscles of the floor draw the rectum and vagina upward and forward with each contraction  premonitory signs of labor o lightening  when the fetus begins to move into the pelvic floor (engagement)  with increased downward pressure the mom may notice:  leg cramps (pressure on nerves)  increased pelvic pressure  increased venous stasis  edema  increased urinary frequency  increased vaginal secretions o Braxton Hicks contractions  false labor, irregular contractions becomes uncomfortable  doesn’t increase in frequency, duration or intensity o cervical changes  softens, stretched & dilates to allow fetal passage (also called ripening) o bloody show  mucous plug is expelled, resulting in small amount of blood loss from exposed cervical capillaries  considered a sign of impending labor, within 24-48hrs o rupture of membranes (ROM)  after amniotic membranes rupture, 80% of women will experience spontaneous labor within 24 hours  fluid can also be expelled in small amounts instead of all at once  spontaneous rupture of membrane (SROM)  occurs at the height if an intense contraction, gush of amniotic fluid out of the vagina  must contact CNM to avoid infection or prolapsed cord if engagement did not occur (umbilical cord expelled)  amniotomy or artificial rupture of membrane (AROM) – amniohook used by physician to rupture membrane  premature rupture of membrane (PROM)  rupture and leakage of amniotic membrane before labor at any gestational age  preterm premature rupture of membrane (PPROM)  membrane rupture before 37 weeks o sudden burst of energy (nesting)

UNIT 2 NORMAL LABOR AND DELIVERY  approximately 24-48 hours before labor o other signs  weight loss from fluid loss or electrolyte shifts produced by changing estrogen & progesterone hormone levels  increased backache and sacroiliac pressure due to influence of relaxin hormone on the pelvic joints  diarrhea, indigestion, or nausea and vomiting just before onset of labor STAGE OF LABOR & BIRTH  First Stage o begins with beginning of true labor, ends when cervix is completely dilated at 10 cm  Physiological changes  increased cardiac output  Slight increased heart rate  Increased WBC with active labor  BP remains the same  GI ○ Nausea and vomiting, decreased absorption (patients should be NPO)  Renal ○ A full bladder and a full rectum can impede labor (slows the progress) and cause discomfort, Proteinuria = increased metabolic activity and a sign of PIH (pregnancy induced hypertension) o divided into 4 phases o latent/early phase  begins with the onset of regular contractions  effacement, little to no fetal descent  nullipara (8.6-20hrs), multipara (5.3-14hrs)  contractions increase in frequency, duration, intensity  duration 20-40sec, frequency of 3-30mins, 25-50mmHg in intensity  excitement is high, mother is able to cope with contractions & discomfort  Nursing Interventions ○ History ○ Lab work  CBC, VDRL, Rh, GC, Chlamydia  GBS (Group B Streptococcus) – baby can get sepsis if the mother is positive for GBS. Treatment: Ampicillin ○ Did the pregnant woman attend childbirth classes? ○ Assess the fetus and contraction status  The jelly is for the FHR, not the uterine contractions (toco) ○ Urine ○ IV: Sometimes Pitocin is added to make the contractions stronger ○ G,P,K (Glucose, Protein, Ketones)  Starting to burn stored fat and energy by not eating ○ External fetal monitoring ○ Comfort measures: liquids or ice chips  Psych: mom feels able to cope with discomfort, relieved labor has begun, talkative, and is able to answer questions, best time to give anticipatory guidance, breathing techniques and other techniques Check MOM: BP, pulse & RR (Q1H), Temp Q4h (unless over 99.6 or ruptured membranes then (Q2H), UC Q15-30 minutes, notify physician if BP is over 135/85 or pulse is over 100

UNIT 2 NORMAL LABOR AND DELIVERY Check FETUS: FHR Q30mins (110-160 w/o decelerations) active phase  anxiety increases  decreased ability to cope & sense of helplessness  cervix dilates from about 4 to 7 cm  contraction frequency 2-3 mins duration of 50-60 sec, moderate intensity  progressive fetal descent, vaginal discharge and bloody show increase Nursing Interventions ○ Assess labor progression (contractions) ○ FHR q30minutes ○ Assess dilation, effacement, station, contractions ○ IV, Pitocin ○ Comfort measures / hygiene ○ Increased bloody show & vaginal discharge ○ Void b/c full bladder interfere with fetal descent ○ Cold feet, provide socks ○ Thirst, dry mouth ○ Rupture of membranes (ROM); color, odor, FHR right after Check for prolapsed cord with vag exam (drop in fetal heart rate) o

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Vital signs  BP, pulse & RR Q1H, (Q30mins for high risk) Temp Q4H, assess UC Q15-30mins ○ Medicate with contractions  Medicating in this stage might slow the labor  *Medications should be given in the first stage ○ Increased perspiration ○ Family and client support (3P’s)  Position, Praise, Pee Pee! (Make sure the bladder is always empty)  Psych: fears a loss of control, sense of dependence, o transition phase  restless, frequent change of position, tired  cervical dilation slows, from 8 to 10 cm, rate of fetal descent increases  contractions are more frequent every 2-3mins, longer duration 60-90 sec & increase in intensity  increased rectal pressure, uncontrolled urge to bear down, refrain from pushing until cervix is completely dilated  increase in bloody show & rupture of membrane  woman feel pressure with peak of contraction, feels abd might burst open, split apart  hyperventilation, difficulty understanding directions, discomfort, anger at contractions, increased sensitivity to touch, support, nausea, crying, yelling  woman feels she “can’t take it anymore” Nursing Intervention o Care measures in 1st stage: encourage position changes, help with hygiene, decrease anxiety, providing information, use supportive relaxation techniques, encouraged paced breathing, administering meds as desired, encourage to void frequently, decrease muscle tension o Contractions palpated Q15mins o Cervical vaginal exam to assess labor status o BP, pulse & RR Q30mins low risk & Q15mins high risk o Mom less aware of what is around her, concentrates on contractions ○

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UNIT 2 NORMAL LABOR AND DELIVERY o Encourage rest b/w contractions 

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Second Stage o begins with complete dilatation (10cm) and ends with birth of infant o descent of fetal presenting part continues until it reached the perineal floor o as mom pushes intrabdominal pressure is exerted from contraction of abdominal muscles o labia begin to part with each contraction o crowning  fetal head encircled external opening of vagina o cardinal movements in order for birth to occur  descent  flexion – resistance of soft tissue of the pelvis cause fetal to chin flex downward on chest  internal rotation – fetal head rotates to fit the diameter of the pelvic cavity  extension  restitution – passage of shoulders causes neck to twist; once head emerges and is free of resistance, the neck untwists, turning the head to one side (restitution) and aligns with position of the back in the birth canal  external rotation – as shoulder rotate, the head is turned farther to one side  expulsion – shoulders slip under pubic symphysis, body follows quickly Be sure to note the delivery time Nursing Intervention o BP, pulse & RR Q5mins, FHR Q5mins o Comfort measures: provide cool washcloth while pushing, she may want to switch gowns for a new one, warm abdominal perineal and back compresses o Perineal massage and stretching o Rest between contractions, sips of fluid or ice chips o Assist doctor with preparing the room and clamping and cutting the cord Third Stage o begins with birth of infant, ends with expulsion of placenta o placenta begins to separate from uterus and descends into vagina 5-30 minutes after birth o placental expulsion signs:  globular shaped uterus  a rise of the fundus in the abdomen  sudden gush or trickle of blood  further protrusion of the umbilical cord out of the vagina o Schultze mechanism (shiny Schultze)  Placenta detached from inside to outer margins, fetal side presenting o Duncan mechanism (dirty Duncan)  Separated from outer margins to inside, rolls up and presents maternal side first o Make sure to note time of expulsion & mechanism o To prevent postpartum hemorrhage, make sure all the placenta came out o Fundus is palpated, should be midline at or below umbilicus  if it is displaced it is d/t full bladder or collected blood in uterus o oxytocic drugs (Pitocin) may be given to stimulate uterus to avoid third stage hemorrhage  10U IM when anterior shoulder appear in vaginal opening, or at time of placenta expulsion

UNIT 2 NORMAL LABOR AND DELIVERY  Or 10-20 U oxytocin added to IV fluid over a period of hours  Methylergonovine maleate (Methergine) 0.2mg IM  Not given if preeclampsia is present 

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Fourth Stage o 1-4 hours after birth o physiologic adjustment of mother’s body begins o blood loss ranges from 250-500mL o blood is redistributed into venous beds, resulting in moderate drop in blood pressure, increased pulse pressure, and moderate tachycardia o uterus remain contracted and is in midline of abdomen  constricts blood vessels at the site of placenta implantation o woman may be thirsty and hungry o may have hypotonic bladder from trauma, may lead to urinary retention Monitor for the first urination after delivery, measure o If mom is unable to pee:  Place warm towel across abd  pour warm water over perineum  pour spirits of peppermint into bedpan to help urinary sphincter relax Check the fundus, lochia (postpartum vaginal discharge), and perineum every 15 minutes. If fills one pad in less than 15 minutes, HCP Maternal attachment Hydrate and feed the mother when she is stable Apply ice to the perineum (front to back) Monitor episiotomy site o Hematoma can develop on the inside of the site Clean the perineum and medicate Notify physician: o Hypotension, tachycardia, uterine atony (boggy), excessive bleeding & Temp over 38C (100F) Transfer to the Postpartum unit Cardiovascular system o Stressed by uterine contractions, pain, anxiety & apprehension o Resting pulse rate increases by 10-18 beats per minute o Strong contractions decreas...