Transcript findings - Villanova University

Intrapartum
Labor and Delivery
5 factors to consider in planning
your nursing care
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Passenger: the fetus
Passageway: pelvis, uterus, vagina
Powers: contractions, pushing
Position: of mom
Psych response: culture, experiences,
preparedness, etc.
The Passenger
• Head Diameter
– suboccipitobregmatic 9.5
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occipitofrontal 11.5
occipitomental 12.5
biparietal 9.5
bitemporal 8
• Shoulders
Lie
• Fetal lie- the
relationship of the
long axis of the baby
to the long axis of the
mother
– horizontal
– longitudinal
Presentation
• Fetal presentation
– part of the fetus closest
to the pelvic inlet
Fetal Attitude
• The relationship of the
fetal parts to each
other
“Universal Flexion”
Station and Engagement
• Station--the
relationship of the
biparietal diameter of
the infant to the ischial
spines of the mother
• Engagement=station 0
Floating/ballotable
Position
• The relationship of fetal landmarks
(denominators) to the maternal pelvis
occiput=head flexed
mentum=head extended (face presentation)
brow=head partially extended
sacrum=breech
acromium process=shoulder
Categories of
position/presentation
VERTEX
• ROA
• LOA
• ROT
• LOT
• ROP
• LOP
• OA
• OP
BREECH
• RSA
• LSA
• RST
• LST
• LSP
• RSP
• SA
• SP
The most common fetal position
Asynclitism
frank
Breech presentations
complete footling
Determination of Position,
Presentation, Lie, Attitude,
Station, and Engagement
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Ultrasound examination
Leopold’s Maneuvers
Vaginal Exam
Location of fetal heart sounds
Placenta
• Previa
• Abruptio
• Normal Placental
Separation
• Placenta Accreta
The passage
pelvis
• Measurements
• Parts
• Types
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gynecoid
anthropoid
platypeloid
anthropoid
Soft Tissue
• Uterus
• Cervix
• Vagina
The powers
Uterine contractions
“pushing”
POWERS
• PRIMARY
– contractions
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frequency
regularity
duration
intensity
• SECONDARY
– maternal bearing-down
Uterine Contractions
Contraction wave starts
in pacemakers at the
cornual ends of
fallopian tubes and
descends down to
lower uterine segment
The Maternal Position
Gravity and Cardiac Output
Psychological Response
Psychological Response
• Maternal Past
experiences
• preparedness
• support
• financial stability,
impact of another
child
• other children to care
for
• cultural meaning of
children, fertility
The Process of Labor
Initiation of Labor
“Lightening”
Cervical “ Ripening”/Effacement
Premonitory Signs of Labor
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Lightening
cervical ripening
1-3lb wt loss
increase in vaginal secretions
mucous plug expelled
backache
braxton hicks contractions
“nesting”
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True Labor
False Labor
Regular contractions
Interval shortens
Increasing intensity
Back to abdomen
Walking increases pain
No effect from mild sed.
Bloody show
Dilatation of the cervix
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Irregular contractions
Interval same
Intensity same or less
Felt in abdomen
Walking decreases pain
Sedation relieves pain
No show
0-ft dilatation
Causes of the Onset of Labor
• Changes in uterus, cervix, pituitary
• Fetal hormonal secretions
• Increasing uterine
– distension
– intrauterine pressure
• Aging placenta
MECHANISM NOT COMPLETELY
UNDERSTOOD
Mechanism of Labor
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Engagement
Descent
Flexion
Internal Rotation
Extension
Restitution
Expulsion
Engagement
• Biparietal diameter of
the baby reaches the
ischeal spines of the
mother
Descent
• Pressure
• uterine contractions
• maternal bearingdown
Measured by station r/t
ischial spines
Flexion
• The smallest diameter
into pelvis
• Pressure of uterus on
breech causes chin to
flex on chest
Internal Rotation
• Baby turns from OT to
OA (usually)
other positions possible
e.g. OP
Extension
• Head extends upward
In a normal vertex
delivery the head is
born by the process of
extension
External Rotation
Also called restitution or
shoulder rotation
The head returns
(restitutes) to the
position it was in
when it entered the
pelvis. The shoulders
are then able to be
delivered.
Expulsion
The baby is delivered
THE STAGES OF LABOR
FIRST STAGE
From onset of labor to full dilitation and effacement
• latent stage (0-3 cm)
• active stage (4-7 cm)
• transitional phase (8-10 cm)
• “complete” at 10 cms
First Stage of
Labor
• Cervical Dilitation 1-10 cm
Signs of transition
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Increased bloody show
rectal pressure
tremors in thighs, legs
Feels she is losing control
Second Stage, from full diliation
and effacement to delivery
Third stage--delivery of Placenta
Placental Separation
Placental separation occurs because the uterus
contracts but the placenta cannot, so it
buckles and separates
Pressure of the uterine walls cause it to slide
downward
Gentle fundal pressure and traction on the
cord complete its delivery
Mechanisms of Placental
Expulsion
• Duncan (maternal side first--separates from
edges 30% of the time)
• Shultz (fetal side first--separates in center
70% of the time)
Fourth Stage
• Fourth stage of Labor
• four hours after
delivery--stabilization
period
Maternal and Fetal Adaptations
to delivery
Maternal Adaptations
All systems affected
Cardiovascular--uterine shunting during labor
• Blood volume 40% at term
• CO2>50% during labor
• Heart rate increases
• Supine hypotension syndrome
NEVER LEAVE A LABORING WOMAN
SUPINE
Respiratory
• more efficient gas exchange (increase in
alveolar ventilation
• diaphragm displaced upward so FRC 
• Capillary Engorgement in respiratory tract
leads to edema and friability of mucous
membranes.
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Gastrointestinal Changes
GI-- motility
 food absorption
lower tension of esophageal sphincter
higher gastric acidity and gastric volume (r/t
placental secretion of gastrin)
• Increased intragastric pressure (from uterus)
Danger of vomiting and aspiration of
vomitus during labor. Antacid may be
given before CS or delivery
Renal Function
• Renal-- GFR
• Renal plasma flow 75% above normal
• Glycosuria due to increased load of glucose
by GFR
• Dilitation of the renal calyces= incidence
of urinary tract infections
Endocrine--progest.
oxytocin, PGs
Musculoskeletal--  lactic acid
Integumentary--diaphoresis
FETAL ADAPTATIONS
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Measured via FHT’s
Fetal scalp sampling
Vaginal vs. C-sect birth
Rising PCO2 levels during second stage and
after cord cut initiate respirations
Fetal scalp blood sampling
NURSING IMPLICATIONS
FOR LABOR AND DELIVERY
Initial L&D assessment
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Ht. And Wt. and gain
EDC
maternal age
allergies
med/surg/ob history
lab work
prenatal care
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Contractions
FHT’s
vaginal discharge
ROM?
Color of fluid
Support person
interaction with
support person
Physical exam--Leopolds Maneuvers
Vaginal Exam
Determines
• Presentation
• Position
• Station
• Effacement
• Dilitation
• Molding
Fetal Heart Tones
Rupture of Membranes (ROM)
• Artificial AROM
• Spontaneous SROM
• Premature PROM
– Nitrazine test to
determine if fluid is
urine or amniotic fluid
Amniotic Fluid
Note:
• Color
• Character
• Amount
• Odor
Check fetal heart tones after ROM, possibility
of prolapsed cord
Infection possible with rupture >24hrs
Labor Monitoring
Contractions
Time
• Frequency
• Duration
• Intensity
• Interval
• Regularity
• Degree of uterine
relaxation between
contractions
Fetal Monitoring
• Baseline FHT-between contractions
Normal 120-160 BPM
Labor is a fetal stressor
Reduction of O2 with
every contraction
Fetal Tachycardia
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Prematurity
mild hpoxia compensation
tocolytic agents
maternal fever
BMR
Atropine or vagal inhibitors
activity
infection
Fetal Bradycardia
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Hypoxia
drugs
maternal hypotension
cord compression
fetal heart block or anomaly
impending demise
Variability, the beat to beat
changes in heart rate
Possible causes of variability
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Sleeping infant
Prematurity
Anomalies
Anticholinergics, e.g. atropine
Analgesicics
Hypoxia
Accelerations
• The increase in fetal heart tones with
contractions or fetal movement
• Positive indicator of fetal adjustment to
stress
Early Decelerations
Early Decelerations
Begin with the contraction and return to
baseline after the contraction
No treatment necessary
These are normal
Variable Decelerations
Variable Decelerations
V shaped or U shaped decelerations of
variable onset
• ascertain type
• positional changes
• pelvic exam to see if cord has prolapsed
• O2 by mask at 10L/min
Late Decelerations
Late Decelerations
Decelerations in which the FHT does not
return to baseline p contraction
Particularly ominous if coupled with
decreased variability
• Give O2 at 10L min
• Reposition (off vena cava)
• DC oxytocin infusion
• If not improved--immediate delivery
External Monitoring
Internal Monitoring
Obstetrical Emergencies
Prolapsed Cord
• ROM with presenting
part high and
unengaged
• Malpresentation
• Polyhydramnios
Nursing Actions
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Trendelenburg Position
Knee Chest Position
Hold Presenting Part up with a gloved hand
Notify Physician/Midwife
Anticipate Immediate Delivery
– C section if delivery not imminent
– Vaginal delivery only if ready to deliver
Fetal Distress
• Late Decelerations or prolonged variables,
low or absent variability with bradycardia
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Turn on L side
Administer O2
Discontinue Pitocin
Notify MD/midwife if not improved by nursing
actions
Other Emergencies
• Placental abruption
• Uterine rupture
• Eclampsia
Uterine Hyperstimulation
Failure of the uterus to
completely relax in
between contractions, or
contractions closer than
1” apart.
• Turn off pitocin
• Turn onto L side
• Administer O2
• Monitor FHT’s
• Notify MD
Admission to Labor Unit
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VS, FHT’s
 Status of Membranes
Onset of Labor
Contractions--run a baseline monitor strip
Vaginal Exam
Possibly ambulate and clear liquids
Supporting Measures
Position
• Upright
• L side if in bed
• Ambulate if not
contraindicated
Breathing techniques
• watch for
hyperventilation
Support People
Coach,
emotional support
nourishment,
comfort measures
Pain in Labor is NORMAL
Caused by:
• hypoxia of compressed muscle cells
• compression of nerves in cervix or LUS by
interlocking muscle fibers
• stretching of cervix
• stretching of perineum
• bladder distension
• tension/anxiety/fear
• oxytocin (stronger contractions)
Non pharmacologic pain relief
methods
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Acupuncture
TENS
distraction
ambulation
imagery
hydrotherapy
therapeutic touch
hypnosis
acupressure
positioning
Pain Relif in Labor
Analgesia and Anesthesia
Analgesia
• Narcotics--can affect baby (Narcan)
– demerol, morphine, stadol
• Tranquilizers
– vistaril(hydroxyzine), phenergan
(promethazine)
• Sedatives
– secobarbital, etc.
Anesthesia
• Local (sub-q injection into the perineum)
• Regional
– paracervical, pudendal, epidural, spinal
• General
– inhalation
– intravenous
Choice of analgesia or anesthesia
based on
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Pt. Condition
labor status
risks
personell
• local practice
• physician’s preference
• pt’s preference
Goal of anesthesia/analgesia
Pain relief that’s simple to use w/o
• endangering mother or baby
• decreasing efficiency of uterine contractions
• diminishing ability of mom to cooperate
• causing need for operative intervention
PUDENDAL BLOCK
Epidural Anesthesia
• Rapid infusion of RL IV to prevent
hypotension
• Causes sympathetic blockade and BP
• Position uterus off of vena cava
• Monitor BP q. 3 minutes until stable
• Monitor FHT, frequently (fetal
bradycardia)
Culture and Childbirth
• FOB has differing roles according to culture
• Must consider cultural differences
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expression of pain
modesty
importance of extended family
rites and rituals concerning placenta, and
cutting the umbilical cord
Nursing assessment in 2nd stage
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FHT’s
Contractions
BP
Control
Effectiveness of
bearing down efforts
• Perineal status
Assessment findings in 2nd Stage
Objective:
increasing bloody show
BP up with bearing down
Subjective:
irritable
Duration:
if < 2hr, MD will intervene
Breathing--needs coaching
Nursing Dx
• Ineffective breathing pattern
• altered comfort
• ineffective coping pattern
Implementation of Nursing Care
• Support
• Encouragement
• Rest between
pushes/contractions
• positioning
Preparation for Delivery
• The room
• the warmer, infant
supplies
• delivery supplies
• perineal prep
Delivery
• Assess position
• avoid precipitous
delivery--control!
Episiotomy
Dystocia--difficult labor
• Abnormal contraction pattern
– primary and secondary uterine inertia
• Bony Dystocia
– CPD (cephalo-pelvic disproportion)
• Soft Tissue Dystocia
– previa, tumors, cervical edema
Dystocia
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CPD
malposition
malpresentation
multiple gestation
Induction of Labor
Indications
• PIH, preeclampsia
• post term
• previous precipitous delivery
• distance from hospital
• convenience
Dangers of Induction
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Prolapsed cord
prolonged labor
pain
prematurity
failureCS
uterine hypertonus rupture
lacerations
hemorrhage
fetal anoxia
precipitous delivery
Induction of Labor
(Stimulation/Augmentation
• Natural--nipple stimulation
• Medical
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AROM
“Stripping” membranes
Laxatives/enemas
Laminaria
• Chemical
– oxytoxics
– prostaglandins
Forceps Delivery
• Full diliation
• engaged head
• no CPD
Vacuum Extractor
• Requires ROM
• Vertx presentation
• No CPD
Cesarean Delivery
• Classical or Low
Cervical
• Usually a regional
anesthetic, unless
emergency--then
general
Indications for Cesarean delivery
Maternal factors
PIH, Diabetes, Heart
dis.,Infections (herpes),
age?
Fetal Status
distress, death, anomalies
Mat/Fetal Factors
Dystocia, Inertia, FTP,
Uterine rupture, Hemm.,
prolapsed cord, CPD,
malpres., plac. Insuff.
Miscellaneous factors
Previous C sections
multiple gestations
monitoring?
Defensive medicine?
Consumer pressure?
Lack of experience with
difficult deliveries?
VPB syndrome?
(very precious baby)
VBAC
• Vaginal Birth After Cesarean
• Usually attempted unless previous classical
incision or type unknown
Requisite for VBAC
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Previous low cervical incision
No CPD
No placenta previa or abruption
“double set up” and prep
Careful monitoring
 oxytoxics
single fetus
vertex presentation
Malpresentations
Breech extraction step 1
Breech extraction step 2
Breech extraction step 3
Breech extraction step 4
Breech delivery (Piper forceps to
aftercoming head)
Shoulder Dystocia
Etiology
• Macrosomia due to maternal diabetes
• Prolonged gestation
• Fetal anencephaly
Shoulder dystocia delivery
Shoulder dystocia delivery
Uterine Atony
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Large baby
Long labor
grand multipara
multiple gestation
MgSO4
Retained placenta