NS2P1 OB Exam 2: Intrapartum
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Labor Vs. Delivery
Labor: Coordinated ssequence of involuntary intermiten uterine contractions
Delivery: Actual Event of Birth
=> The Four Major Factors: .
1. Powers: Uterine contractions; forces acting to expell the fetus including Effacement (shortening and thinning of the cervix during the first stage of labor) and Dilation (Enlargement of cervical os and cervical canal during the first stage of labor) AND the pushing efforts of mother duing second stage.
2. Passageway: Pelvis, cervix, vagina, introtius (external opening)
3. Passenger: The fetus, membranes, and placenta
4. Psyche: Emotional response to labor, anxiety, fear.
the relationship of fetal body parts to one another.
- -Normally intrauterine attitude:
- Flexion- head to chest, knees to abd, arms crossed.
Relationship of the sppine of the fetus to the spine of the mother
-Longitudinal/Vertical: Spine paralllel to mother's (either cephalic or breech)
-Transverse/Hori: Fetal spine at a right angle to mother's.. Presenting part is shoulder (C-section!)
- Portion of the fetus that enters the pelvic inlet first
- 1. Cephalic: Head first.
- 2. Breech: Butt first
- 3. Shoulders: Fetus is a transverse lie; csection if you can't turn the fetus manually.
Relationship of assigned area of the presenting part or landmark to the maternal pelvis.
-ROA is normal: Right Occipitoanterior (ref point: occiput)
The measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine.
- Station 0: AT ischial spine
-Minus Station: Above ischial spine
-Plus: Below ischial spine
-Engagement: when widest diameter of the presenting part has passed the inlet; corresponds to a 0 station.
Linda: The infant is engaged at 0 and delivered at 5.
=> Mechanistms of Labor:
d. Internal Rotation
g. External rotation
a. Engagement – Fetal is nestled in pelvis (fetal lightening/dropping down)
b. Descent – Fetal head undergoes magical thru the magical pelvis
c. Flexion –Nodding of fetalhead towards fetal chest
d. Internal Rotation – Fetus turns to side to prepare for movement thru birth canal
e. Extension – Begins after head crowns; enables head to crown
f. Restitution – Realignment of fetal head with body after head emerges
g. External rotation – Shoulders externally rotate after head emerges
h. Expulsion – Birth of entire body
=> True vs. False Labor:
-True: Contractions may manifest as backpain in some women, contractions often respmble menstrual cramps during early Labor. Dilation and effacement are progressive.
-False: aka prodromal labor; contractions felt in abdomen and groin and may be more annoying than painful. Contractions are irrecular. No dilation, effacement or descent occurs.
=> Fetal Monitoring:
-Normal Baseline FHR: 110-160.
1. External monitor: noninvasisve, used with tocotransducer oor doppler ultrasound. Mom is allowed to move but avoied "vena cava compression": Maternal supine hypotensive syndrome.
2. Internal fetal monitoring: Invasive and requires rupturing of the membranes and attaching an electrode to the presenting part of the fetus; client must be dilated 2-3 cm
Brief Temporary Increase means?
Fluctuations in baseline FHR.
can result form feal hypoxemia, acidosis, or certain meds-temp decrease in variabily can occur when the fetus is in a sleep state (not longer than 30 mins)
- 3. Brief temp increases in FHR of at least 15 beats/min and lasting at least 15 seconds is usually a reassuring sign; occurs with fetal movement
- -Periodic: In relatiionship to the contractions vs. non-perioidic
DECELS- Early (Myles)
- benign or abnormal
- -Early decels- gradual decrease longer than 30 sec in and return to baseline fhr associated with contractions, transient head compression, vag exam due to fundal pressure, placement of fetal mon.
oUsually occur at 4-7cm 1st stage sometimes when woman is pushing in 2nd stage.
oNot assoc. with fetal hypoxemia, academia, or low apgars.
- Decreases in FHR below baseline, the lowest point of decels usually remains greater than 100 bpm.
- -Not associated with fetal compromise and require no interventions.
- -when pushing: we toleratate decles b/c baby is going to be out soon
NONREASSURING patterns that reflect impaired placental exchange or uteroplacental insufficientcy.
-Patterns looks similar to early decels but begins well AFTER the contraction begins and return to baseline after the contraction ends
-late decels: turn women on their sides; turn on left side to geet off the vena cava..
LATE DECELS- gradual decrease in return to baseline FHR assoc with contractions. Starts after contraction startedo Starts at cont. lowest point occurs at peak on cont. does not return to baseline until after contraction is over.
Maternal hypotension, uterine tachysystole (usually from oxytocin administration), epidural, placenta previa, placental abruption, hypertensive disorder, post maturity, intra uterine growth rest. DM, amniotic infection.
Ominous when assoc. with minimal variability. Abnormal patterns assoc. with fetal hypoxemia, academia, low apgars
Interventions—change to lat pos. , elevate legs , in iv rate, palpate uterus to assess tachysystole , discontinue oxytocin, o2 8-10 l/ nrb mask, tell drr, consider internal mon. assist with birth is necc.
Caused by conditions that restrict flow through the umbilical cords; don't have unifrom appearance of early and late decelps. Fall and rise abruptly with onset and relief of cord compression. Can also be nonperiodic.
-Significant when it falls below 70 bpm for at least 60 seconds.
- Variable decels- abrupt decrease in FHR baseline.
- - 15 beats below BL for more than 15 sec. and returns with in 2 min.
- - during UC phase caused by compression of umbilical cord.
- - Have a U,V, W, shape with rapid decent and ascent- Sometimes followed by accels to compensate “shoulders”
- - Occasional= no significance.
- - Recurrent= repetitive disruption of o2 supply to fetus. hypoxemia, academia. Usually during 1st or 2nd stage. Dur to umb, cord comp. and stretching during decent-
Short cord, cord around neck, knot in cord, prolapsed cord.
- Usually transient and correctable.
change pos side to side knees to chest.o DC oxytocin, o2 8-10 l/min nrb mask, tell dr, assisst with vag exam, amnioinfusion, birth
- decerease abrupt or gradual, of at least 15 beats/ min for more than 2 min but less than 10.
-CAUSES- maternal hypo, uterine tachysystole/ rupture, placental insufficiency, prolonged cord compression or prolapse.
Interventions when pushing and fetal late decels (push every other contraction, position changes, O2 mask, fluid bolus…)
=> Hypertonic Unterine Activity:
Assessing performed by palpating by hand or using IUPC: Internal Uterine Pressure Cath.
-The Uterus should relax b/w contractions for 60 seconds or longer.
-If hypertonic: uterine resting tone b/w contractions is high, reducing uterine blood flow and decreasing fetal oxygen supply
**NonReassuring FHR Patterns:
Brady & tachycardia
Late Decels Prolonged Decels
Hypteronic Uterine Activity
Variable decels falling to less than 70 bpms longer than 60 seconds
**Priority Nursing Actions for Nonreassuring FHR:
1. Identify cause
2. Disconfiny oxytocin/Pitocin Infusion b/c increases uterine stimulation
3. Change mother's positiion
5. Possible csection prep
**STAGE ONE OF LABOR
The longest, uses Friedman Curve
=> Active Phase:
- => Latent Phase: Cervical dilation: 1-4 cm; Uterine contractions Q15-30 min and 15-30 sec duration
- -Interventions: Breathing patterns, quiet environment, pillow and possition changes, Fluids/Ice Chips, Encourage voiding 1-2 hours
Cervical dilation: 4-7 cm; Uterine contractions Q3-5 min and 30-60 sec duration
Rest b/w contractions, quiet enviroment, fluids/ice chips, void Q2H
=> Transition Phase:
Cervical dilation: 8-10 cm; Uterine contractions Q2-3 min and 45-90 sec duration
weake mom at beginning of contraction so she can begin creathing pattern.
=> Stage 1 Interventions:
Monitor mom's vitals, and FHR, monitor uterine contractions, assess cervical dilation and effacement, assess fetal station and position by Leopold's maneuvers.
**STAGE TWO OF LABOR:
Cervical dilation is complete, progress of labor is measured by descent of fetal head through birth canal (change in stations), Increase in bloody show occurs and mother feels URGE TO PUSH.
=> Interventions: Perform assessments Q5mins, Monitor signs of appropaching birth: Perineal bulging or visualization of fetal head and prep for birth (expulsion of fetus)
**STAGE THREE OF LABOR:
- Contractions occur until placenta is expelled, placental separation and expulsion occurs, 5-30 mins after infant birth
- -Shiny Schultze and Duncan
Assess maternal vitals, uterine status, promote parental-neonatal attachment.
**STAGE FOUR OF LABOR:
Period of 1-4 hours after Delivery,
BP prelabor, pulse is slightly lower, Fundus remains contracted in the midline.
- => Interventions: mom assessments q15 for 1 hr, Q30min for hour and then hourly for 2 hours.
- -Apply icepacks to the perineum, Massage uterus
difficult labor that is prolonged or more painful, occurs because of problems caused by uterine contractiions, the fetus, or the bones and tissues of the maternal peelvis
-Dysfunctntial labor for ambonroal uterine contractions preventing normal progress of : cervical dilation, effacement (primary power), and descent (secondary powers)
-Position of the woman
-Psychological responses: hormones and neurotransmitters released in response to stress can cause dystocia.
-Abnormal Labor patterns: preciptious labor: Lasts less than 3 hours from onset of contractions to birth.
-Hypotonic contractions: More common type; secondary uterine inertia offer pitociin
-Hypertonic: painful, occure uncoordinated and frequent (prime momary); often anxious first time mother
=> Assessment: Excess abdominal pain, abnomal contraction pattern, Fetal distress, Mom/baby tachycardia, Lack of progress in Labor.
=> Interventions: Administer prophylactic antibiotics to prevent infection, administer intravenous fluids, monitor intake/Output, hydration, Monitor color of amniotic fluid.
Stimulates fetal lung maturation by promoting release of enzymes that induce production or rlease of lung surfactant
-B/w 24 to 34 weeks of gestation (prenatal glucocorticoid)
-Adverse reaction: maternal infection (IM inj), pulm edema
**Prolapse of Umbilical cord:
when cord lies below presenting part of fetus; contributing factors include: Long cord, malpresentation (breech) Transverse lie, unengaged presenting part
-endagners fetal circulation
**Dysfunctional labor Patterns for Nulliparas Patients
Prolonged latent phase:
Longer than 20 hours in the nullipara and 14 hours in the multipara.
- Associated with:An unripe cervix
- Too-early use of analgesics or sedation
- Too-early use of conduction anesthesia
- Nearly 1/3 of abnormal labors
**Dysfunctional labor Patterns: Protracted active phase
Occurs when dilatation is <1.2cm/hr in the nullipara and <1.5cm/hr in the mulitpara.
- Associated with:
- CPD-Cephalopelvic disproportion (CPD) occurs when a baby’s head or body is too large to fit through the mother’s pelvis.
Minor malpresentations, OP or transverse occiput
Amniotomy before or at onset of labor
Conduction anesthesia before active labor is established
**Dysfunctional labor Patterns: Secondary arrest of the active phase
Occurs when cervical dilatation stops in the active phase.
- Associated with:
- Excessive sedation or conduction anesthesia
- AROM-Artificial Rupture of Membranes
**Dysfunctional labor Patterns: Precipitous labor
Occurs when cervical dilatation is >5cm/hr in the nullipara and 10cm/hr in the multipara.
- Associated with:
- A normal latent phase in nulliparas
- Oxytocin administration
- Uncomplicated and spontaneous vaginal deliveries
**Factors Affecting Labor : Position of laboring woman
Position affects woman’s anatomic and physiologic adaptations to labor
- => Frequent changes in position
- Relieve fatigue
- Increase comfort
- Improve circulation
->Laboring woman should be encouraged to find positions most comfortable to her
*Process of Labor
Labor: process of moving fetus, placenta, and membranes out of uterus and through birth canalVarious changes take place in woman’s reproductive system in days and weeks before labor begins
Labor can be discussed in terms of mechanisms involved in process and stages woman moves through
=>Signs preceding labor: Lightening or dropping, Bloody show
=> Onset of labor: Onset of true labor cannot be ascribed to single cause. Many factors involved, including changes in maternal uterus, cervix, and pituitary gland
1. Stages of Labor: which one Varies more in length
a. She’s going to think that the worst is over
b. First Stage of Labor – Effacement & Dilation of Cervix; 3 phases = Latent (Dilation 1-4cm, active (4-7cm) and transitional (8-10cm)
c. Stage 2 –Pushing stage (expulsion of fetus)
d. Stage 3 – Separation and expulsion of placenta (Gush of red blood/fluid = placenta is coming)
e. Stage 4 is physical recovery
Interventions with Epidurals
- -sit w back curved, shoulders parallel, legs slightly flexed back arched.
- - PLACE CATHETER IN EARLY LABOR WHEN PT IS COMFORTABLE AND COOPERATIVE. GIVE EPIDURAL WHEN LABOR IS WELL EST. 4-5 CM
- after epidural placed, put woman on side.
- => PRE- Give 500- 1000ml ive bolus of NS or LR 15
- -30 MIN BEFORE, monitor BP for hypotension
- - obtain lab results
- - assess pain, assisnt woman to void
- => DURING
- - proper pos, verbally guide, doc VS, time and meds given, monitor VS BP and FHR, o2 ready, mon signs of toxicity.
- - s/s of hypo- <100 systolic, fetal bradycardia, mini abset FHR variability
- turn women on side with pillow under hip maintain
- iv infusion
- administer o2 w non rebreathing mask 10-12 L/min
- elevate legs
- notify Dr
- IV vaso suppressor
- Chech FHR and BP q5 min
- - instruct when to bear down
- - check for bladder dist, bed pan or catheter, change pos side to side every hour, keep catheter site clean and dry
return of motor function
measure HR and contraction strength (duration and intensity)-contraction must go up and down to 5-10.
Most conclusive sign that uterine contractions are working-internal electronic monitoring with an intrauterine pressure catheter - dilation
Labs for epidural
=> Platelets, hematocrit, hemoglobin, WBC.
Informed Consent: what's the Nurse Role
clarify, describe procedures, or by acting as woman's advocate and ask dr for further explanation.
Advantages and disadvantages, agreement with plan of pain care, consent given freely.
=> <110 FHR
-caused by fetal cardiac problem (structural or failure) or viral infections (cytomegalovirus), maternal hypoglycemia, maternal hypothermia.
-heart block, medications, FH failure.
what are the legal responsibilities of the perinatal nurse?
=> a. Interpret fhr, initiate appropriate nursing interventions, document outcomes
Different colors for the amniotic fluid. Normal? Abnormal?
=> Normal amniotic fluid – color, odor, consistency- pale, straw, with white particles,
if green = meconium: the earliest stool of a mammalian infant. Unlike later feces, meconium is composed of materials ingested during the time the infant spends in the uterus
SROM. Nurse's initial response? What are you looking for?
=> SROM risksinfection- amniotis and placentitis
Breast feeding benefits for mom and baby
- helps contract.
=> a. Regulates baby’s temperature, releases oxytocin which causes uterine contractions which stops bleeding
=> Steroid to promote surfactant secretion in preterm birthbetamethisone- given IM to mother to accelerate fetal lung maturinty by stim sufactant production
- reduce severity of resp distress syndrome.
- Bethamethasone 12 mg 2 doses 24 hrs apart
- Dexamethason 6 mg 4 doses 12 hrs apart
- Dec fetal rr and movement.
- Give in gluteal or vastus lateralis, IM inj only., inj is painful, should not affect bp, check blood sugar.
=> Mature baby lungs after 29 weeks, before 38
Good Labor Patterns with IUPC --effective labor Pattern?
Augumentation vs Induction of Labor
=> Augmentation of labor:
- -stimulation of uterine contractions after labor has started but not progressing as should.
- -Implemented for management of hypotonic uterine dysfunction
- -oxytocin or amniotomy
Once SROM: Increased Rsk for ?
=> infection- amniotis and placentitis
Nulliparous woman in 2nd stage of labor – description
-dilation 10 cm and complete effacement. -latent phase: calm, relaxed, sense of relief, fatigue sleepy, “worst is over”
- active phase: urge to bear down, change pos freq for comfort, vocal, screaming, grunting, out of control, ring of fire, powerlessness, excitement after head shows.
How do you know 2nd stage of labor has begun
& Fundus Shape
- mom has urge to push, pressure on pelvi, inability to feel cervix indicating full dilation, feeling of having to BM
Fundus shape of multiparous woman-firm, size of a grapefruit, will be on the right side if bladder is full
Early Signs of Recognition of Labor:
- Uterine Activity/COntraction
- Progressive Cervical Change
- -Effacement of 80% and Cervical dilation of 2 cm or greater.
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