OB Intrpartum Period
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What maternal and fetal factors contribute to the start of labor?
- Maternal: stretching of the uterine muscles, increased pressure on cervix releases oxytocin, increased estrogen (due to decreased progesterone) stimulates contractions
- Fetal: placental aging leading to contractions, prostaglandin synthesis by fetal membranes and decidua lead to contractions, fetal cortisol leads to a decrease in progesterone production by placenta and increase in production of prostaglandin
What are the s/s of impending labor?
- Lightening (two weeks prior to labor in primigravidas)
- Braxton hicks contractions
- Surge in energy (nesting)
- Cervical changes
- Diarrhea, indigestion, N/V, weight loss
- Backache (due to relaxation of the pelvic joints)
- Bloody show
What are the factors affecting labor?
- PASSENGER: Fetus
- PASSAGEWAY: Bony pelvis, cervix, vagina, and the pelvic floor
- POWERS: Uterine contractions
- PSYCHE: mother's ability to cope with the labor process
- POSITION: of the mother
How are uterine contractions (powers) assessed?
- Frequency: start of one to the start of the next
- Duration: start to finish
- Intensity: Can only truly be monitored by an IUPC, however they can also be palpated at the fundus for strength
Whose cervix tends to efface and then dilate?
- Primigravidas tend to efface and then dilate
- Multigravidas will dilate and then efface
What are the two different kinds of tissue when considering the passageway of birth?
- Soft Tissue: cervix, pelvic floor, vagina, bladder
- Bony Pelvis: relaxin and estrogen soften cartilage and increase elasticity of ligaments to allow room for the fetal head during birth
When considering the passenger (infant), what different physical relationships between the mother and fetus need to be considered?
- The fetal skull position
- The fetal attitude
- The fetal lie
- The fetal presentation
- The fetal size
Describe the best way for the fetal skull to enter the pelvis
- The vertex (occiput) is the best presenting part
- This is because the head is then flexed and the smallest diameter is then entering the pelvis first
What is molding?
- Molding recurs as a result of the fetal head being pushed through the maternal pelvis
- The suture lines of the skull overlap to allow passage of the fetal skull
What is the lie of the fetus? Why is this important?
- The position of the maternal spine vs the position of the fetal spine
- Fetus can be in a transverse lie (bad) or a longitudinal lie (Expected)
- The fetus much be in a longitudinal lie to move through the maternal pelvis
What is the attitude of the fetus? Why is this important?
- Attitude is also called the posture of the fetus and is the relationship of the fetal parts to one another
- Fetal flexion or fetal extension of the chin and extremities
- Fetal flexion is necessary for descent into the pelvis
What is the presentation of the fetus? Why is this important?
- This is the part of the fetus coming first in the pelvis
- Can be vertex (occiput & preferred), breech, shoulder (dystocia), or compound (arm or hand the presenting part)
What is the position of the fetus? How can it be changed? Why is this important?
- The relationship of the presenting part of the fetus to the quadrant of the maternal pelvis
- The is determined by feeling the fetal skull upon examination
- Can be altered by repositioning mom
- Described by three letters- R (right) or L (left) of moms pelvis, O (occiput) or S (shoulder) or B (breech) presenting part, and A (anterior) or P (posterior) or T (transverse) part of the mother's pelvis
Describe the station of the fetus and the definition of engagement
- Station describes the relationship of the presenting part to the ischial spines of the maternal pelvis
- "O" is the level of the ischial spines and is called engagement. A positive station is the baby moving past the ischial spines (+3 gets the crown, +4 is on the floor)
- Engagement occurs PRIOR to labor in PRIMIgravidas and during labor for multiparas
Why is the mother's psyche important during the birth process?
- The women's cultural and individual values influence how she will be able to cope with childbirth (high anxiety can slow down labor due to catecholemines, which relax smooth muscle)
- Childbirth is an incredibly emotional time and emotions change throughout the stages of labor
- The nurse can promote a positive experience by incorporating as many of the family's birth expectations as possible
How can the nurse provide emotional, informational, and physical support during the labor process?
- Emotional support (to all members): continuous presence, reassurance, praise
- Information: labor progress, coping techniques
- Comfort Measures: touch, massage, bath/showers, adequate fluid intake, output
- Advocacy: assisting the woman and her family in being involved in the birth and respecting their birth place whenever possible
What positions of the mother can be used during the first stage of labor?
- Upright- walking, sitting, kneeling, squatting (gravity is your friend!)
- Position changes reduce fatigue, increase comfort, improves circulation, aids in decent of the fetus, and decreases compression on the IVC
What positions of the mother can be used during the second stage of labor?
- Upright positions increase the pelvis outlet and helps to align the fetus with the pelvic outlet
- However, the lithotomy position is the most common in the US
What is the difference between true and false (braxton hicks) labor?
- True labor must have BOTH cervical changes and regular contractions
- False labor with irregular contractions is usually relieved by activity, such as walking, and hydration
- True labor is often accompanied by bloody show and increasing contractions
What is the most important thing to assess when ROM occurs? Why???
- Assess the fetal heart tones!!
- Umbilical cord prolapse can occur during ROM, which can stop O2 to the baby
- Umbilical cord prolapse is an emergency
What measures should be taken if prolapsed chord occurs?
- Call for the physician immediately
- With sterile gloves, insert 2 fingers into vagina to relieve pressure from the presenting part onto the cord
- Put mother in knee to chest or trendelenburg position to relieve pressure in pelvis
- Apply sterile, NSS soaked dressing to cord if it is outside vagina
- Provide continuous monitoring of FHT
- Admin O2 at 8-10 liters via mask
- IV fluid bolus
- Keep the mother informed about condition and talk her though everything that may happen
What is AROM, SROM, PROM, and PPROM?
- AROM: Artificial rupture of membranes
- SROM: Spontaneous rupture of membranes
- PROM: Premature rupture of membranes
- PPROM: Premature Preterm rupture of membranes
How is ROM verified?
- Nitrazine paper: amniotic fluid is alkaline and will turn the paper blue
- Speculation exam of the vagina for pooling of fluid
- Ferning of fluid on slide under microscopre
What should be assessed at the time of ROM?
- Color- should be clear
- Odor- maybe a dewey odor, not foul
What are the cardinal mechanisms of labor? describe each one
- Engagement: the greatest part of the fetal head enters the maternal pelvis inlet either late in the pregnancy or early in labor (station 0)
- Descent: During the first an second stage of labor, the movement of the fetus through the pelvic canal
- Flexion: early in labor when the descends in head meets resistance and pushes the fetal chin towards the fetal chest
- Internal Rotation: fetal head rotates to align the long aids of the fetal head with the long axis of the maternal pelvis, during stage 2 of labor
- Extension: The presenting part is pivoted beneath the pubic symphysis and is delivered. This occurs due to the resistance in the pelvic floor
- External Rotation: the shoulders align in the anterior-posterior diameter to align the sagittal sutures to a transverse diameter. As the trunk comes through the pelvis, this allows the shoulders to pass through the pelvis
- Expulsion: shoulder and the remainder of the body are delivered and stage 2 ends
Describe the stages of labor
- Stage One: Latent phase, active phase, transition phase. Begins with the onset of labor and ends with completion of cervical dilation and effacement
- Stage Two: begins at completion and ends with the birth of the baby
- Stage Three: begins with the birth of the baby and ends with the passing of the placenta
- Stage Four: First four hours post partum until mother is stable
What is the ideal time for mom to be admitted during labor?
- The active phase of stage one is the ideal time for mom to be admitted
- During the latent stage, mom can stay home and relax
What pain meds can be used during the first stage of labor?
- During the first stage of labor, an epidural may be given, esp during the active phase
- Other analgesics include meperidine (demerol), butorphanol (stadol) or sublimaze (fentanyl)
- If the mother is experiencing anxiety, promethazine (phenergan) or hydroxyzine (vistaril) may be used and it also potentiates the pain meds
- If there is a prolonged latent phase, zolpidem (ambien) or morphine may be used to promote rest
What pain meds can be used during the second stage of labor?
- An epidural block, spinal block, pudendal block, or general anesthesthia may be used
- The most important thing to remember is that any medications used within an hour of birth can cause respiratory depression in the baby (such as stadol)
What is fergusen's reflex?
The feeling that mother needs to push or bear down. It is best to wait until this time for the mother to begin to push
What is the difference between open glottis and closed glottis pushing?
- Open glottis pushing is shorter, more natural pushing segments
- Closed glottis pushing is the more traditional method of holding your breath and pushing for 10 seconds. This is associated with decreased O2 for both the mother and baby, petechiae in the mother's face and HTN
What are the nurse's responsibilities during the fourth stage of labor?
- Monitoring vitals q15 for the first hour, q30 for the second hour, q4 hr for the next 22 hr and then once per shift
- Nurse should assess BUBBLEHEP
- Oxytocin may be used to firm up the uterus
What three major assessments are done during admission?
- Fetal Condition
- Maternal condition
- S/S of impending birth (priority assessment, how far into labor are we?!)
What medications are used during the fourth stage of labor?
- Ibuprofen (motrin)
- Lidocaine (for repair)
- Oxytocin to firm the fundus
- Colace to soften stool
- Simethicone for gas
During the admission process, what should the nurse consider, assess, and advocate for?
- Establish therapeutic relationship
- Start IV and blood work, such as CBC and T&C (large bore, at least 18g)
- Consider GBS status and necessity of prophylactic antibiotics
- Assess cultural and religious needs
- Advocate for the client's birth plan and desires whenever medically appropriate
What factors contribute to the mother's reaction to pain during labor?
- Previous experience
- Perception of pain is influenced by culture
- Anxiety reduces pain tolerance
- If the labor was spontaneous, the body releases endorphins to help prepare for and manage pain
What nursing measures support pain management?
- Encourage position changes
- Assist with personal comfort measures
- Decrease Anxiety
- Provide information
- Use specific supportive relaxation techniques
- Encourage paced breathing
- Admin Pharmacological agents as requested by woman
- Support the woman and her support group
What are some non-pharmacological pain management techniques?
- Child birth preparation
- Relaxation and breathing techniques (assess for hyperventilation)
- Thermal stimulation (warmth or cold)
- Mental stimulation including focus, imagery, music,and diversion
- Support person
- Birthing ball
What are some types of analgesia used during the labor process?
- Meperidine (demerol)
- Butorphanol (stadol)
- Sublimaze (Fentanyl
What anti-anxiety meds can be used during the labor process?
- Promethazine (phenergan)
- Hydroxyzine (Vistaril)
What nursing actions should be performed when administering analgesics during labor?
- Pain assessment (number and location)
- Assess history of drug abuse(as a higher doe may be needed)
- Assess progression of labor as respiratory depression in the fetus can occur if given within 1 hr from birth
What kinds of anesthesia can be used during labor?
- Local (lidocaine for repair of laceration)
- Pudendal block (numbs vagina and perineum for episotomy or forceps assisted birth)
- Epidural Block (catheter in the epidural space of the spine)
- Spinal Block (sublimaze into the subarachnoid space of the spine and only lasts 3 hrs)
- General anesthesthia (used for emergencies. trauma, spinal deformity or fusion, or low platelets. Agents reach infant in 2 mins and stop respiration, so fast delivery is necessary)
What are the side effects of anesthesia during labor? What nursing actions should be taken?
- Vasodilation of blood vessels leading to hypotension: preload mother with IV fluid prior to anesthesia (about 1L in 30-60 min), monitor maternal VS & BP, lateral or upright position to avoid supine hypotension, assess FHT for bradycardia
- Loss of Stimuli to Void: will need to empty bladder on a regular basis until birth or may need to be cathed, will need to empty bladder again during the recovery period
- Uterine Contractions: frequency may decrease, no action needed or oxytocin may be ordered (labor should be well established prior to admin of anesthesia)
- Spinal Headaches: monitor for HA and notify anesthesiologist
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