OB Intrapartum Period
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When assessing if it is true or false labor, the nurse must assess..?
Status of Cervix
Status of membranes (BOW)
True vs. False Labor
True vs. False Labor
What are the preliminary signs of true labor
- Lightening --> baby "drops", relief of pressure on the diaphragm and stomach, increased pressure on bladder
- Increased vaginal secreations
- Slight weight loss
- Mucous plug, bloody show
- Thinning and softening of cervix
- Persistent backache
- Increased braxton-hicks (intermittent painless uterine contractions)
What is important with the status of the membrane?
Bag of Water (BOW)
- Assess C.O.A.T
- Color of fluid --> clear or mecomium stained
- Amount of amniotic fluid
- Time of rupture
How do you confirm ruptured membranes?
Nitrazine Swab test --> Vaginal fluid swabbed with nitrazine swab. If swab turns blue, fluid is alkaline which confirms amniotic fluid
Fern Test --> vaginal fluid swabbed and placed on microscope slide. Fern pattern confirms amniotic fluid
What is part of the admission of a labor patient?
- Provide emotional support
- Determine stage of labor
- Assess fetal heart tones (FHT)
- Determine status of membranes
- Other information:
- Gravida/para; problems, EDD
- Blood type, Rh factor, CBC
- Vital signs
- Last food and fluid
What are the common solutions used in OB?
Isotonic --> therefore no shifts between ECF and ICF
What are the 5 P's of the labor process?
- 1) Passenger (fetus)
- 2) Passageway (pelvis)
- 3) Powers (contractions)
- 4) Position of mother
- 5) Psychological factors (psyche)
relationship of the widest diameter of the presenting part and the ischial spines of the pelvis
relationship of the fetal parts to one another (flexion, extension)
relationship of the longitudinal axis of the fetus (spine) to the longitudinal axis (spine) of the mother (longitudinal, oblique, transverse)
fetal part entering the pelvis first
relationship of the fetal presenting part to the maternal pelvis
What are the 4 ways to determine fetal position?
- Leopold's Maneuvers
- Vaginal exam
- Auscultation of fetal heart rate (FHR)
continues throughout labor. If this does not occur, none of the other mechanisms can occur
level of ischial spines into the pelvic inlet
must occur now for other mechanisms to follow. Head and neck flex, allowing the smallest diameter of the head to come first
may be prolonged, head must rotate up to three times in order to pass navigate the pelvic canal
allows head to pass under pelvic arch
involves two movements allowing shoulders to position
rest of the body follows the anterior shoulder
All of the cardinal movements depend on proper coordination of the...?
Stages of Labor:
Latent --> Cervix dilates from 0-3 cm
Active Phase --> Cervix dilates from 4-7 cm
Transitional --> Cervix dilates from 8-10
Stages of Labor
Complete dilation and baby is born
- Cervix is now fully dilated (complete)
- Only then can mother begin pushing
- May take only 1 push to deliver the baby but may also take 1-2 hours of pushing Exhausting! Mother may fall asleep in between contractions
- Baby is delivered
Stages of Labor:
Placenta is delivered
- Cord clamped; delivery of placenta
- Vagina, cervix and perineum inspected and repaired if needed
- Assess fundal height, firmness
- Massage fundus (manually contracts the uterus)
- Give oxytocin (chemically contracts the uterus)
- Promote family bonding/breastfeeding
Stages of Labor
Immediate recovery period; 2 hours after
- First hour is critical for monitoring mother
- Hemorrhage is the major complication
- Assessments q 15 minutes X 4; then q 30 min. X 2 (or as per agency protocol)
- Family bonding continues to be priority once safety of mom and baby established; prompt
- breastfeeding encouraged as this decreases bleeding by facilitating uterine contractions
First stages of Labor (3 phases)
What are possible perineal traumas?
- Lacerations --> perineal lacerations usually occur when head is being delivered
- extent defined in terms of depth:1st-4th
- Skin (1st) through rectal wall (4th)
- Episiotomy --> Incision made in perineum to enlarge the vaginal opening
- More common in US/Canada than Europe
Effacement of Cervix
shortening and thinning of the cervix, measured in percentages (25%,50%,75%,90%,100%)
Dilation of the Cervix
- Opening of the cervix, measured in cm
- Cervix dilates to a max. of 10 cm
- Cervix can be closed, fingertip, 1-10 cm
What are the different fetal presentations?
- mentum (chin)
Describe what station or degree of engagement is
-5 station (high)
station (at mid-pelvis or ischial spines)
+5 station (at outlet, crowning)
Describe the relationship of station and engagement
When the fetal head is level with the ischial spines, fetus is engaged
Level of engagement is zero (0) station
What does it mean to induce labor?
Initiation of labor by artificial means
- Oxytocic simulation - use of oxytocin
- Response varied greatly from person to person, so must be closely monitored and titrated
What are the indications for the induction of labor?
- Dysfunctional labor --> augment labor
- Fetal demise --> no heart tones
- Post-term pregnancy
- Maternal complications (diabetes, hypertension)
- The higher the score, the greater the success of induction of labor
>9 (out of 13) indicates induction is warranted and may be successful
What are the methods of induction of labor?
- Prostaglandin gel which ripen the cervix (Examples: Cervidil and Prepidil)
- Evening primrose oil also known to ripen cervix
- Oxytocin administration (assists with contractions)
- Artificial rupture of membranes (AROM)
Describe the process of AROM and what is important to assess before and after.. and why?
- Artificial rupture of membranes (AROM) requires the physician using an amniotomy hook
- Membranes may rupture spontaneously (SROM) with movement of the fetus
- In either situation, it is essential to confirm fetal well-being by assessing fetal heart tones
- Why? Risk of prolapsed cord when fluid gushes out of vagina
#1 priority... determine fetal well being!!!
What are the uses for oxytocin?
- 1) Induction of labor
- 2) Augmentation of labor
- 3) Contraction stress test (CST)
- 4) Prevention of hemorrhage after birth
How do you calculate a pitocin drip rate?
What are the factors that influence pain during labor?
- anxiety and feer
- previous experience
- childbirth preparation
- comfort and support
What are some natural pain control methods that can be used during labor?
- relaxation and breathing
- effleurage and sacral pressure
- therapeutic touch
Describe systemic drugs used in labor
Stadol (butorphanol tartrate)
Morphine --> less common
Both meds cause significant respiratory depression in the infant if administered too close to delivery
If so--> infant given Narcan IM to counteract effect
What are the different types of anesthesia used in OB?
- Local --> episiotomies
- Pudendal block --> major perineal repair
- Lumbar epidural block --> vag birth (epidural)
- Subarachnoid (spinal) block --> Csection
- General anesthesia --> emergency Csection
What are the advantages and the disadvantages of an epidural?
- Mother alert, cooperative, relaxed
- Airway and reflexes intact, only motor paralysis
- Gastric emptying not delayed
- Fetal distress rare
- Can be modified quickly to allow mother to push
- Provides rest period for long labors
- IV required
- Occasional dizziness
- Weakness of legs, not able to ambulate
- Difficulty emptying bladder
- Hypotension, convulsions or parasthesias
- Increased C-sections due to inability to bear down
- Occasional high spinal anesthesia resulting in depressed/arrested respirations
What is important to remember about spinal blocks?
- Higher anesthetic effect than with epidurals; may impede ability to breathe
- Can respiratory depression/arrest
- Respiratory rate must be assessed every hour for 24 hours after birth in C-section mothers
- who had a morphine spinal block
What is a spinal headache and how is it treated?
If spinal fluid leaks through the tiny puncture site, patient may develop a spinal headache due to decreased fluid pressure around the brain/spinal cord
Described as “a headache like no other”
Other symptoms may include nausea, dizziness, sensitivity to light, neck stiffness
Most spinal headaches resolve on their own
Lying flat, IV fluids, caffeine helps with symptoms
However spinal headaches lasting more than 24 hours may require a blood patch
What is the purpose of a blood patch and how is it performed?
The anesthesiologist inserts a needle into the same space as, or right next to, the area in which the anesthetic was injected
He/she then takes a small amount of blood from the patient and injects it into the epidural space. The blood clots and seals the hole that caused the leak
Resolves the spinal headache
What are the different ways to facilitate bonding/attachment?
- skin-to-skin (kangaroo care)
- father cutting the cord
- family-centered care
What are the different ways one can prepare for child birth?
- International Childbirth Education Association
- C-Section Teaching
- Baby care
- Daddy Boot camp
What are the different possible problems with the passenger?
Prolapsed Umbilical Cord
When a fetus has a prolapsed cord, describe the cause as well as what you will see on the FHR monitor.
Cause: fetus is not firmly engaged, allowing room for the cord to move beyond (prolapse) or along the presenting part
Causes fetal distress due to decreased circulation
Variable decels will display on FHM
What are the nursing interventions for a prolapsed cord?
- Knee-chest or Trendelenburg position
- Examiner pushes presenting part upward to relieve pressure on the cord
- If cord protrudes through the vagina, apply sterile saline soaked dressing
- O2 by face mask at 8-10 L/min
- Prepare for rapid delivery
What is fetal distress and what are the causes?
Insufficient oxygen supply to meet the demands of the fetus
- Umbilical cord compression
- Decreased oxygenation to fetus relaxation of anal sphincter passage of meconium stool and gasping
- Fetus may aspirate meconium (MAS). Always suction airways before chest expansion
Consider amnioinfusion to dilute the meconium
What are the possible problems with the passageway
- Cephalopelvic Disproportion (CPD)
- Fetal head is too large to pass through the bony pelvis
- Shoulder dystocia
- Obstetrical emergency resulting from difficulty/inability to deliver the shoulder
- Inadequate amount of amniotic fluid to facilitate vaginal birth
What would you do as a nurse during an incident of shoulder dystocia during a birth?
- Use McRoberts positioning
- Apply suprapubic pressure
- Do not use fundal pressure
- Notify NICU; infant may be pale or shocky
- Document thoroughly and carefully
Why should you NEVER use fundal pressure during a delivery?
Can cause uterus or bladder to rupture
- Fetus cannot withstand the pressures of labor without the cushioning effect of fluid
- Normal amount at term is 800-1,000 mLs
- Vaginal birth requires a 2 cm pocket of amniotic fluid around the fetus
- If less than 2 cm; C/Section is required
- Inadequate amounts may be related to problems with fetal renal development
- Some NSAIDs (ibuprofen/indomethacin) will decrease fluid production
- Excessive amounts of amniotic fluid
- May be related to problem with GI fetal development
- Excess fluid stretches the uterus; places the mother at risk for postpartum hemorrhage
- Amniocentesis can be performed to removed excess fluid
- Ibuprofen/indomethacin therapy helps decreases fluid production
What are the different "problems with the powers"?
- Labor Dystocia
- Hypertonic uterine contraction pattern
- Hypotonic uterine contraction pattern
- Premature Labor
- Contractions occurring between 20-37 weeks gestation
Describe labor dystocia
- Difficult labor that is prolonged or more painful
- Occurs because of problems caused by ineffective uterine contractions
- Contractions may be hypotonic or hypertonic
- Dystocia can result in maternal dehydration, infection, fetal injury or death
What is uterine hypersystole?
6 or more contractions in a 10 min period
single contraction lasting longer than 2 min
Uterine hyperstimulation happens when either condition (uterine hypersystole or uterine hypertonus) leads to a ________________.
Non-reassuring fetal heart rate pattern
What is preterm labor and how is it caused?
Onset of regular contractions resulting in cervical change between 20 and 37 weeks gestation.
- Major causes:
- Dehydration --> rehydrate with PO fluids and IV therapy
Infection --> treat the infection (UTI, URI) with antibiotics
What are the signs and symptoms of preterm labor?
- Contractions occurring q 10 minutes or less
- Dilated to 1 cm or more 80% or more effacement
- Low abdominal cramping with or without diarrhea
- Intermittent pelvic pressure, urinary frequency
- Low back ache (constant or intermittent)
- Increased vaginal discharge
- Leaking amniotic fluid
What are the nursing interventions for preterm labor?
- Monitor uterine activity and FHR
- Administer tocolytic agents which relax smooth muscle and stops contractions
- Terbutaline (Brethine)
- Ritodrine (Yutopar)
- Nifedipine (Adalat)
- Magnesium sulfate
Administer corticosteriods (betamethasone or dexamethason)
- Administered to mother at 28-34 weeks
- Crosses placenta to stimulate fetal lung maturity and production of surfactant
- Peak effect is 48 hours after initiation of therapy
- Betamethasone:12 mg I.M. Q 24 hours X 2 doses
What are the influencing factors that can cause problems with the psyche?
- Fear and anxiety
- Perception of the problem
- Preparation for childbirth
- Support systems
- Coping ability
What are the nursing interventions to help a patient experiencing problems with the psyche?
- Establish a trusting relationship with the patient and family
- Remain at bedside during labor
- Encourage relaxation
- Keep patient/family informed about progress/procedures
- Encourage positive coping behaviors and discourage negative behaviors
What are the major indications for c/sections?
- Dystocia or CPD
- Fetal distress
- Breech presentation
- Previous cesarean birth
What are the risk of cesarean deliveries?
Maternal --> apiration, hemorrhage, infection, injury to bladder/bowel, thrombophlebitis, pulmonary embolism
Fetal --> Prematurity, injury at birth, respiratory problems related to delayed absorption of fetal lung
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