Labor and Birth Processes Nursing Care During Labor and Birth 2024, Exams of Nursing

Download Labor and Birth Processes Nursing Care During Labor and Birth 2024 and more Exams Nursing in PDF only on Docsity! LABOR AND BIRTH PROCESSES NURSING CARE DURING LABOR AND BIRTH 2024. OBJECTIVES • Describe the process of labor and the major factors affecting it and the associated nursing interventions that enhance labor progress. • Describe maternal and fetal adaptations to labor. • Develop a plan of care that enhances labor progress for labor and birth. • Review the factors included in the initial assessment of the woman in labor. • Describe the ongoing assessment of maternal progress during the first, second, and third stages of labor with and without risk factors identified. • Recognize the physical and psychosocial findings indicative of maternal progress during labor. • Describe the influence of cultural and religious beliefs and practices on the process of labor and birth. • Discuss ways the nurse can use evidence-based practices to enhance the quality of care a woman receives during labor and birth. Quick Overview of Anatomy: • Baby sits inside pelvis Factors Affecting Labor • The 5 P’s of Labor: Passenger, Passageway, Powers, Position of laboring woman, Physiologic response (maternal) o Passenger : fetus and placenta ▪ Size of fetal head – fontanels allow for some movement; the baby’s head can mold to fit the mother’s pelvis; if the baby’s head is bigger than the mom’s pelvis = cephalopelvis disproportion ▪ Fetal presentation ▪ Fetal Lie – relation of the long axis (spine) of the fetus to the long axis of the mother; longitudinal (baby’s spine is longitudinal to mother’s spine) ▪ Attitude – the relation of the fetal body parts to one another; vertex with full flexion or general flexion  ; military ▪ Position – relationship of the presenting part to the four quadrants of the mother’s pelvis ➢ First letter – tells us the location of the presenting part, in either the right or the left side of the pelvis ➢ Second letter – presenting part of the fetus ➢ Third letter – location of the presenting part to the anterior, posterior, or transverse portion of the pelvis o Passageway: birth canal ▪ Bony pelvis ▪ Soft tissues – lower uterine segment – retraction ring ▪ Cervix, pelvic floor, vagina, introitus Presentation – Part of the fetus that enters the pelvic inlet first • Cephalic – head first o Vertex – general flexion and the occiput is the general presenting part o Face o External cephalic version – version of the fetus from breech to vertex presentation; 36/37 weeks is ideal for performing this • Breech – buttock, foot, or feet o Frank Breech ▪ Lie – Longitudinal or vertical ▪ Presentation – breech (incomplete) ▪ Presenting Part – sacrum ▪ Attitude – flexion, except for legs at knees o Single Footling Breech ▪ Lie – Longitudinal or vertical ▪ Presentation – breech (incomplete) ▪ Presenting part – sacrum ▪ Attitude – flexion, except for one leg at hip and knee o Complete Breech • Lithotomy position – in stirrups • Semi-recumbent position • Lateral position The 5 P’s of Labor – Psychologic Response – Maternal • Unique to each woman • Cultural beliefs • Previous experience • Anxiety level • Environment • Wanted or unwanted pregnancy? • Adolescent? • Adoption? • Relationship with spouse/significant other • Labor support – family, spouse, doula, birth attendant • Physical/psychological condition entering labor • Pain -tolerance/expectations for pain management • Physiologic Adaptation to LABOR • Maternal adaptation – Woman exhibits both objective and subjective symptoms o Cardiovascular changes ▪ 400 ml. of blood emptied from uterus into maternal vascular system during a contraction ▪ C.O. during contractions increased by 51% by end of 1st stage ▪ C.O. peaks 10-30 min after vaginal birth and C/S; returns to prelabor baseline within one hour postpartum ▪ Slight decrease in heart rate accompanies increase in C.O. ▪ Both systolic and diastolic pressures increase during contractions; return to baseline between contractions ▪ Systolic values increase more than diastolic ▪ Supine hypotension – gravid abdomen ways too much and it smashes the aorta and vena cava; the blood and oxygen isn’t coming through to the placenta; usually left lateral increases perfusion by getting the baby off of those blood vessels ▪ Valsalva maneuver during pushing – Intrathoracic pressure,  venous return, venous pressure. C.O. and BP and pulse  temporarily. Fetal hypoxia may occur; process reverses when woman takes a breath o Respiratory changes ▪ Increased RR as a result of increased physical activity, pain, anxiety and increased oxygen consumption ▪ Hyperventilation can occur in response to pain – respiratory alkolosis, hypocapnia ▪ Common in transition – overwhelming urge to push ▪ How can you treat hyperventilation? Model how they should breathe o Renal changes ▪ Spontaneous voiding may be difficult due to pain, position, pressure of baby, tissue edema ▪ Epidural influences ▪ Proteinuria of +1 normal as result of muscle tissue breakdown from work of labor o Integumentary changes ▪ Skin flushed as a result of pain, work of labor ▪ Extreme stretching of perineum during second stage ▪ Degree of distensibility varies with individuals ▪ Lacerations and minute tears in perineum and vagina can occur o Musculoskeletal changes ▪ Backache (unrelated to fetal position) and joint ache common as result of increased joint laxity at term ▪ Leg cramps common – never massage a pregnant woman’s calf – you could dislodge a clot o Neurologic changes ▪ Sensorial changes can occur as woman progresses through labor ▪ Initially calm, happy about being in labor ▪ Increased seriousness as labor progresses and requires focusing on coping techniques ▪ Elation and fatigue after giving birth ▪ Endorphins effecting pain perception o Gastrointestinal changes ▪ During labor GI motility and absorption of solid foods decreased; stomach-emptying time slowed ▪ Nausea and vomiting of undigested food after onset of labor common ▪ Nausea and vomiting common in transition and full dilation ▪ BM during labor and delivery process common o Endocrine changes ▪ Onset of labor may be triggered by decreased progesterone & increased estrogen, prostaglandins, and oxytocin ▪ Metabolism increases ▪ Blood glucose decreases with work of labor • • Physiologic Adaptation to Labor – Fetal Adaption • Fetal heart rate (FHR) o Term gestation normal range 110-160 o Temporary accelerations and decelerations occur in response to fetal movement, contractions, vaginal exams, fetal cord compression, etc. • Stress to uterofetoplacental unit causes characteristic FHR patterns • During contractions, fetal circulation decreases through spiral arterioles with subsequent decreased perfusion through intervillous space – Fetal adaptation o C.O. = stroke volume x heart rate • Admission to labor and delivery o EMTALA – **Legal Tip box** pg. 432 o OB Triage and prioritization of patient care • Admission data o Review prenatal record & consents (if available) o Perform admission interview o Review birth plan and patient advocacy o Review childbirth education classes • • Admission Interview • Complaint or reason for coming? • Estimated date of confinement (EDC)? o LMP with Naegele’s Rule o Pregnancy Wheel • GTPAL or G/P? o Gravida – number of all pregnancies; para – number of deliveries after 20 weeks o Term – number of term deliveries (37-42 weeks) o Preterm (Term + Preterm = Para) – number of pre-term deliveries (20-35.5 weeks) o Abortion (Spontaneous or Elective/Therapeutic) – miscarriage or elective; any pregnancy ending prior to 20 weeks o Living – living children • Current pregnancy problems? o High blood pressure o Gestational Diabetes (GDM) o Ever saw a MFM specialist (perinatologist)? • Previous pregnancy problems? o Maternal or Fetal Complications? – Postpartum hemorrhage ; NICU stay o Previous birth experience? • Breast or bottle-feed? • Pediatrician? • Labor preferences/ Birth plan? • Height / Weight / Allergies (reaction type)? • Surgical history? What kind of surgery is particularly important? • Medical history? • Family medical history? • Social history? • Home meds? • • Admission Assessment • Admission data o Focused assessment based on maternal risk o Psychosocial factors ▪ Appropriate appearance and behavior ▪ Victim of domestic violence ▪ Depressed or suicidal o Women with history of sexual abuse  Triggered memories during labor experience o Stress/Fears in labor  Nurse-client relationship o Cultural Considerations (Box pg. 437) ▪ Father present/participating ▪ Non-English speaking • • Considerations • Non-Traditional Families o LGBTQ o Adoption o Surrogacy o Don’t assume anything • Non-Traditional Conception o Meds/ IUI/ IVF o Egg/ Sperm donation o Embryos o Surrogacy • Cultural Considerations (p. 437) o Support Persons o Pain Tolerance/ Expression o Diet Restrictions o Rituals surrounding birth • Legal Implications – birth certificate • Assessment • Physical Exam o General systems assessment o Vital signs o Membrane status – nitrazine (expected to turn blue), pooling, ferning o Color and character of fluid o Clear vs. meconium o Leopold maneuvers o Assessment of fetal heart rate (FHR) and contraction pattern • • ROM – Rupture of Membranes • Spontaneous rupture of membranes – SROM • Artificial rupture of membranes o AROM or amniotomy o May be done to induce labor, or if need for internal monitoring is present (fetal stress or maternal obesity) • • Assessment of Amniotic Membranes/Fluid • Normal o Pale, straw-colored; white flecks o Watery; no strong odor • Deviation from Normal o Greenish brown o Yellow-stained o Port-wine colored – blood o Thick, cloudy, foul-smelling - infection o (Poly) Hydramnios o Oligohydramnios • • Assessment of FHR and Pattern • PMI of FHR is where it can be heard the loudest • Usually directly over fetal back (Leopold Maneuvers) • Vertex – usually heard below maternal umbilicus • Breech – usually heard above maternal umbilicus • • Leopold Maneuvers • • Assess Contraction • Frequency • Intensity • Duration • Resting Tone • o ROM possible • Primigravida – dilate 1.2 cm/hour; active fetal descent • Multipara – dilate 1.5 cm/hour; fetal head may stay high, then descend • Duration – averages 3-6 hours • Harder to stay in control; working hard using techniques; sedation or epidural common; may have some difficulty following directions • • 3rd Phase – Transition • 8 to 10 cm of dilation; complete effacement, continued fetal descent • Contractions: o Frequency: 1.5-3 minutes apart o Duration: 45-90 seconds o Intensity: Strong to very strong (forehead) o Bloody show: bloody mucous, may be copious o ROM possible o Vomiting/Bowel movement possible • Duration – 20-40 minutes (can vary greatly!) • Very difficult to focus on techniques and maintain control • Extreme vaginal and rectal pressure with epidural; overwhelming urge to push without epidural • Nausea and vomiting common – enhances dilation and fetal descent – listen to your patient and look under the sheets! • • Nursing Care During Labor • Maternal/fetal assessment – use all of your senses to look at the big picture! • Adequacy of labor/facilitating labor progress o Vital signs/fetal assessment o Maternal temperature o Primigravida vs. multipara labor o Regulating contractions – nipple stimulation, Pitocin o Status of membranes/bloody show • Signs of labor progress – other than cervical change o Change in contraction pattern o Change in level of pain/anxiety – verbal and non-verbal cues o Bloody show o AROM (amniotomy) or SROM – ALWAYS check FHT’s with ROM o Change in FHR – early or variable decels o Maternal BM o Look under the sheets! • • Physical Nursing Care During Labor • The physical nursing care given to a woman in labor is an essential component of her care! • Evidence-based approach o Allow labor to start spontaneously o Encourage freedom of movement o Provide labor support to decrease anxiety and stress and decrease need for anesthesia and C/S o Avoid routine interventions: IV, NPO, decreased oral fluids, continuous monitoring, AROM, labor augmentation o Non-directed pushing in non-supine positions o Avoid separation of mom and baby o Skin to skin contact – keeps baby warm, facilitates bonding, enhances baby’s transition to extrauterine life, fosters early breastfeeding • General hygiene, prevention of infection – peri care, underpads, limit vaginal exams • Nutrient and fluid intake – oral vs. IV • Elimination – voiding, catheterization, BM • Comfort measures/pain relief • Assist with epidural/monitor patient • Ambulation and positioning • • Maternal Progress in First Stage of Labor • Delivery of infant o Dry and Stimulate o Cut umbilical cord o Collect cord blood (testing; banking/donating) • • Process of Labor – Third Stage of Labor • 3rd Stage • 3rd stage last from the birth of the fetus until the placenta is delivered. • Normally separates with 3-4 strong contractions after the baby is born • Duration of 3rd stage can be as short as 3-5 minutes, although up to one hour is considered normal • Risk for postpartal hemorrhage increases as the length of the 3rd stage increases • • Signs of Placental Separation • Firmly contracting fundus • Change in uterus – discoid to globular ovoid shape • Sudden gush of dark blood from the introitus • Lengthening of the umbilical cord • Vaginal fullness • • Collaborative Care • Placental examination and disposal – Cultural preferences • Maternal physical status – Physiologic changes to pre-pregnancy status • Signs of potential problems o Excessive blood loss o Alterations in vital signs and consciousness • Care after placental delivery • Fundal massage ; assess bleeding • Assess bladder • Pitocin – IV or IM; Methergine; Cytotec • Breastfeeding and uterine contraction • Care of family during third stage • Family-newborn relationships • • Perineal Trauma – Repair • Lacerations o Perineal lacerations o Vaginal and urethral lacerations • Episiotomy • Precipitous birth • Documentation • Pull appropriate suture and place on table – Sterile technique • • Immediate Newborn Care • Suction mouth THEN nose • Dry and Stimulate! • Assess vital signs and perform Apgar • Once infant is stable: • Place skin-to-skin! o Physical assessment o Gestational age assessment o Vitamin K – clotting factors o Erythromycin ointment – eye infection o Parent-infant bonding • Apgar Score – Rate at 1 & 5 minutes  Should repeat Apgar at 10 minutes if the 5 min is < 7 o Score 0, 1 or 2 for each category o A ppearance (Color) o P ulse (Heart Rate) o G rimace (reflex irritability) o A ctivity (muscle tone) o R espiration (Respiratory effort) o MUST know scoring guidelines • • • 0 points • 1 points • 2 points • Activity • Absent • Arms and legs flexed • Active Movement • Pulse • Absent • Below 100 bpm • Over 100 bpm • Grimace • Flaccid • Some flexion of extremities • Active motion (sneeze, cough, pull away) • Appearance (skin color) • Blue, pale • Body pink, extremities blue • Completely pink • Respiration • Absent • Slow, irregular • Vigorous cry • Severely depressed – 0 to 3 • Moderately depressed – 4 to 6 • Excellent condition – 7 to 10 • • Process of Labor – Fourth Stage of Labor • 4th Stage • Period of immediate recovery when homeostasis is established – lasts for 2 hours after placenta is delivered • An important time for observation of complications, such as abnormal bleeding, and a time for maternal-infant bonding. • • Postpartum Patient Assessment • B – Breast • U – Uterus • B – Bladder • B – Bowel • L – Lochia • E – Episiotomy/Laceration/Incision • H – Homan’s sign • E – Emotional state • (don’t forget pain!) • • • ▪ UCs: tocotransducer o Internal Monitoring – mother must be ruptured and at least 2 to 3 cm dilated ▪ Spiral electrode - ▪ IUPC – tells you the frequency, duration, and intensity of contractions • • Portable Telemetry Monitor • Allows woman to ambulate in labor while being continuously monitored • Monica AN24 o Abdominally obtained electronic impulses o Monitors both FHR & UA o 5 electrodes on abdomen o Obtains ECG from maternal & fetal heart o Obtains EMG from uterine muscle o Transmitted via Bluetooth • • Fetal Heart Rate Patterns • Baseline FHR o Average rate during a 10-minute segment that excludes: ▪ Periodic or episodic changes ▪ Periods of marked variability ▪ Segments of the baseline that differ by more than 25 beats/min o Must be at least 2 minutes of interpretable data • Variability o Described as irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater o 4 possible categories of variability: ▪ Absence ▪ Minimal – amplitude range is somewhere between 0 to 5 beats/min; can result from fetal hypoxemia or metabolic academia; congenital anomaly; maybe the mother was given pain medication or CNS depressants; maybe sleeping ▪ Moderate – 6 to 25 bpm; this is what we want; this indicates a well oxygenated baby; a normal fetal acid-base balance ▪ Marked – notify physician • Sinusoidal FHR Pattern – a sign of severe fetal anemia and notify physician • Tachycardia: > 160 beats/min  10 minutes or more o Take a temperature – maybe the mother has an infection; if so, notify the physician o Maybe she was given a medication o Maybe the mother smoked some crack o Give her IV fluids, antibiotics, Tylenol, etc. • Bradycardia: < 110 beats/min  10 minutes or more o Sign that there is a fetal cardiac defect o CMV, maternal hypoglycemia, or maternal hypothermia o Treat the underlying cause • Changes in FHR o Periodic changes occur with UCs o Episodic (nonperiodic changes) not associated with UCs o Accelerations ▪ Caused by dominance of sympathetic nervous system response ▪ An indication of fetal well-being ▪ Highly predictive of a normal fetal acid-base balance ▪ Can be periodic (with a contraction) or episodic (without a contraction) ▪ Visually apparent abrupt increase in FHR above the baseline ▪ > 32 weeks’ gestation  15 x 15 (15 beats above the baseline lasting 15 seconds) ▪ < 32 weeks’ gestation  10 x 10 (10 beats above the baseline lasting 10 seconds) ▪ Can happen when the baby moves, or spontaneously o Decelerations LABOR AND BIRTH PROCESSES NURSING CARE DURING LABOR AND BIRTH 2024. OBJECTIVES • Describe the process of labor and the major factors affecting it and the associated nursing interventions that enhance labor progress. • Describe maternal and fetal adaptations to labor. • Develop a plan of care that enhances labor progress for labor and birth. • Review the factors included in the initial assessment of the woman in labor. • Describe the ongoing assessment of maternal progress during the first, second, and third stages of labor with and without risk factors identified. • Recognize the physical and psychosocial findings indicative of maternal progress during labor. • Describe the influence of cultural and religious beliefs and practices on the process of labor and birth. • Discuss ways the nurse can use evidence-based practices to enhance the quality of care a woman receives during labor and birth. Quick Overview of Anatomy: • Baby sits inside pelvis Factors Affecting Labor • The 5 P’s of Labor: Passenger, Passageway, Powers, Position of laboring woman, Physiologic response (maternal) o Passenger : fetus and placenta ▪ Size of fetal head – fontanels allow for some movement; the baby’s head can mold to fit the mother’s pelvis; if the baby’s head is bigger than the mom’s pelvis = cephalopelvis disproportion ▪ Fetal presentation ▪ Fetal Lie – relation of the long axis (spine) of the fetus to the long axis of the mother; longitudinal (baby’s spine is longitudinal to mother’s spine) ▪ Attitude – the relation of the fetal body parts to one another; vertex with full flexion or general flexion  ; military ▪ Position – relationship of the presenting part to the four quadrants of the mother’s pelvis ➢ First letter – tells us the location of the presenting part, in either the right or the left side of the pelvis ➢ Second letter – presenting part of the fetus ➢ Third letter – location of the presenting part to the anterior, posterior, or transverse portion of the pelvis o Passageway: birth canal ▪ Bony pelvis ▪ Soft tissues – lower uterine segment – retraction ring ▪ Cervix, pelvic floor, vagina, introitus Presentation – Part of the fetus that enters the pelvic inlet first • Cephalic – head first o Vertex – general flexion and the occiput is the general presenting part o Face o External cephalic version – version of the fetus from breech to vertex presentation; 36/37 weeks is ideal for performing this • Breech – buttock, foot, or feet o Frank Breech ▪ Lie – Longitudinal or vertical ▪ Presentation – breech (incomplete) ▪ Presenting Part – sacrum ▪ Attitude – flexion, except for legs at knees o Single Footling Breech ▪ Lie – Longitudinal or vertical ▪ Presentation – breech (incomplete) ▪ Presenting part – sacrum ▪ Attitude – flexion, except for one leg at hip and knee o Complete Breech • Lithotomy position – in stirrups • Semi-recumbent position • Lateral position The 5 P’s of Labor – Psychologic Response – Maternal • Unique to each woman • Cultural beliefs • Previous experience • Anxiety level • Environment • Wanted or unwanted pregnancy? • Adolescent? • Adoption? • Relationship with spouse/significant other • Labor support – family, spouse, doula, birth attendant • Physical/psychological condition entering labor • Pain -tolerance/expectations for pain management • Physiologic Adaptation to LABOR • Maternal adaptation – Woman exhibits both objective and subjective symptoms o Cardiovascular changes ▪ 400 ml. of blood emptied from uterus into maternal vascular system during a contraction ▪ C.O. during contractions increased by 51% by end of 1st stage ▪ C.O. peaks 10-30 min after vaginal birth and C/S; returns to prelabor baseline within one hour postpartum ▪ Slight decrease in heart rate accompanies increase in C.O. ▪ Both systolic and diastolic pressures increase during contractions; return to baseline between contractions ▪ Systolic values increase more than diastolic ▪ Supine hypotension – gravid abdomen ways too much and it smashes the aorta and vena cava; the blood and oxygen isn’t coming through to the placenta; usually left lateral increases perfusion by getting the baby off of those blood vessels ▪ Valsalva maneuver during pushing – Intrathoracic pressure,  venous return, venous pressure. C.O. and BP and pulse  temporarily. Fetal hypoxia may occur; process reverses when woman takes a breath o Respiratory changes ▪ Increased RR as a result of increased physical activity, pain, anxiety and increased oxygen consumption ▪ Hyperventilation can occur in response to pain – respiratory alkolosis, hypocapnia ▪ Common in transition – overwhelming urge to push ▪ How can you treat hyperventilation? Model how they should breathe o Renal changes ▪ Spontaneous voiding may be difficult due to pain, position, pressure of baby, tissue edema ▪ Epidural influences ▪ Proteinuria of +1 normal as result of muscle tissue breakdown from work of labor o Integumentary changes ▪ Skin flushed as a result of pain, work of labor ▪ Extreme stretching of perineum during second stage ▪ Degree of distensibility varies with individuals ▪ Lacerations and minute tears in perineum and vagina can occur o Musculoskeletal changes ▪ Backache (unrelated to fetal position) and joint ache common as result of increased joint laxity at term ▪ Leg cramps common – never massage a pregnant woman’s calf – you could dislodge a clot o Neurologic changes ▪ Sensorial changes can occur as woman progresses through labor ▪ Initially calm, happy about being in labor ▪ Increased seriousness as labor progresses and requires focusing on coping techniques ▪ Elation and fatigue after giving birth ▪ Endorphins effecting pain perception o Gastrointestinal changes ▪ During labor GI motility and absorption of solid foods decreased; stomach-emptying time slowed ▪ Nausea and vomiting of undigested food after onset of labor common ▪ Nausea and vomiting common in transition and full dilation ▪ BM during labor and delivery process common o Endocrine changes ▪ Onset of labor may be triggered by decreased progesterone & increased estrogen, prostaglandins, and oxytocin ▪ Metabolism increases ▪ Blood glucose decreases with work of labor • • Physiologic Adaptation to Labor – Fetal Adaption • Fetal heart rate (FHR) o Term gestation normal range 110-160 o Temporary accelerations and decelerations occur in response to fetal movement, contractions, vaginal exams, fetal cord compression, etc. • Stress to uterofetoplacental unit causes characteristic FHR patterns • During contractions, fetal circulation decreases through spiral arterioles with subsequent decreased perfusion through intervillous space – Fetal adaptation o C.O. = stroke volume x heart rate • Admission to labor and delivery o EMTALA – **Legal Tip box** pg. 432 o OB Triage and prioritization of patient care • Admission data o Review prenatal record & consents (if available) o Perform admission interview o Review birth plan and patient advocacy o Review childbirth education classes • • Admission Interview • Complaint or reason for coming? • Estimated date of confinement (EDC)? o LMP with Naegele’s Rule o Pregnancy Wheel • GTPAL or G/P? o Gravida – number of all pregnancies; para – number of deliveries after 20 weeks o Term – number of term deliveries (37-42 weeks) o Preterm (Term + Preterm = Para) – number of pre-term deliveries (20-35.5 weeks) o Abortion (Spontaneous or Elective/Therapeutic) – miscarriage or elective; any pregnancy ending prior to 20 weeks o Living – living children • Current pregnancy problems? o High blood pressure o Gestational Diabetes (GDM) o Ever saw a MFM specialist (perinatologist)? • Previous pregnancy problems? o Maternal or Fetal Complications? – Postpartum hemorrhage ; NICU stay o Previous birth experience? • Breast or bottle-feed? • Pediatrician? • Labor preferences/ Birth plan? • Height / Weight / Allergies (reaction type)? • Surgical history? What kind of surgery is particularly important? • Medical history? • Family medical history? • Social history? • Home meds? • • Admission Assessment • Admission data o Focused assessment based on maternal risk o Psychosocial factors ▪ Appropriate appearance and behavior ▪ Victim of domestic violence ▪ Depressed or suicidal o Women with history of sexual abuse  Triggered memories during labor experience o Stress/Fears in labor  Nurse-client relationship o Cultural Considerations (Box pg. 437) ▪ Father present/participating ▪ Non-English speaking • • Considerations • Non-Traditional Families o LGBTQ o Adoption o Surrogacy o Don’t assume anything • Non-Traditional Conception o Meds/ IUI/ IVF o Egg/ Sperm donation o Embryos o Surrogacy • Cultural Considerations (p. 437) o Support Persons o Pain Tolerance/ Expression o Diet Restrictions o Rituals surrounding birth • Legal Implications – birth certificate • Assessment • Physical Exam o General systems assessment o Vital signs o Membrane status – nitrazine (expected to turn blue), pooling, ferning o Color and character of fluid o Clear vs. meconium o Leopold maneuvers o Assessment of fetal heart rate (FHR) and contraction pattern • • ROM – Rupture of Membranes • Spontaneous rupture of membranes – SROM • Artificial rupture of membranes o AROM or amniotomy o May be done to induce labor, or if need for internal monitoring is present (fetal stress or maternal obesity) • • Assessment of Amniotic Membranes/Fluid • Normal o Pale, straw-colored; white flecks o Watery; no strong odor • Deviation from Normal o Greenish brown o Yellow-stained o Port-wine colored – blood o Thick, cloudy, foul-smelling - infection o (Poly) Hydramnios o Oligohydramnios • • Assessment of FHR and Pattern • PMI of FHR is where it can be heard the loudest • Usually directly over fetal back (Leopold Maneuvers) • Vertex – usually heard below maternal umbilicus • Breech – usually heard above maternal umbilicus • • Leopold Maneuvers • • Assess Contraction • Frequency • Intensity • Duration • Resting Tone • o ROM possible • Primigravida – dilate 1.2 cm/hour; active fetal descent • Multipara – dilate 1.5 cm/hour; fetal head may stay high, then descend • Duration – averages 3-6 hours • Harder to stay in control; working hard using techniques; sedation or epidural common; may have some difficulty following directions • • 3rd Phase – Transition • 8 to 10 cm of dilation; complete effacement, continued fetal descent • Contractions: o Frequency: 1.5-3 minutes apart o Duration: 45-90 seconds o Intensity: Strong to very strong (forehead) o Bloody show: bloody mucous, may be copious o ROM possible o Vomiting/Bowel movement possible • Duration – 20-40 minutes (can vary greatly!) • Very difficult to focus on techniques and maintain control • Extreme vaginal and rectal pressure with epidural; overwhelming urge to push without epidural • Nausea and vomiting common – enhances dilation and fetal descent – listen to your patient and look under the sheets! • • Nursing Care During Labor • Maternal/fetal assessment – use all of your senses to look at the big picture! • Adequacy of labor/facilitating labor progress o Vital signs/fetal assessment o Maternal temperature o Primigravida vs. multipara labor o Regulating contractions – nipple stimulation, Pitocin o Status of membranes/bloody show • Signs of labor progress – other than cervical change o Change in contraction pattern o Change in level of pain/anxiety – verbal and non-verbal cues o Bloody show o AROM (amniotomy) or SROM – ALWAYS check FHT’s with ROM o Change in FHR – early or variable decels o Maternal BM o Look under the sheets! • • Physical Nursing Care During Labor • The physical nursing care given to a woman in labor is an essential component of her care! • Evidence-based approach o Allow labor to start spontaneously o Encourage freedom of movement o Provide labor support to decrease anxiety and stress and decrease need for anesthesia and C/S o Avoid routine interventions: IV, NPO, decreased oral fluids, continuous monitoring, AROM, labor augmentation o Non-directed pushing in non-supine positions o Avoid separation of mom and baby o Skin to skin contact – keeps baby warm, facilitates bonding, enhances baby’s transition to extrauterine life, fosters early breastfeeding • General hygiene, prevention of infection – peri care, underpads, limit vaginal exams • Nutrient and fluid intake – oral vs. IV • Elimination – voiding, catheterization, BM • Comfort measures/pain relief • Assist with epidural/monitor patient • Ambulation and positioning • • Maternal Progress in First Stage of Labor • Delivery of infant o Dry and Stimulate o Cut umbilical cord o Collect cord blood (testing; banking/donating) • • Process of Labor – Third Stage of Labor • 3rd Stage • 3rd stage last from the birth of the fetus until the placenta is delivered. • Normally separates with 3-4 strong contractions after the baby is born • Duration of 3rd stage can be as short as 3-5 minutes, although up to one hour is considered normal • Risk for postpartal hemorrhage increases as the length of the 3rd stage increases • • Signs of Placental Separation • Firmly contracting fundus • Change in uterus – discoid to globular ovoid shape • Sudden gush of dark blood from the introitus • Lengthening of the umbilical cord • Vaginal fullness • • Collaborative Care • Placental examination and disposal – Cultural preferences • Maternal physical status – Physiologic changes to pre-pregnancy status • Signs of potential problems o Excessive blood loss o Alterations in vital signs and consciousness • Care after placental delivery • Fundal massage ; assess bleeding • Assess bladder • Pitocin – IV or IM; Methergine; Cytotec • Breastfeeding and uterine contraction • Care of family during third stage • Family-newborn relationships • • Perineal Trauma – Repair • Lacerations o Perineal lacerations o Vaginal and urethral lacerations • Episiotomy • Precipitous birth • Documentation • Pull appropriate suture and place on table – Sterile technique • • Immediate Newborn Care • Suction mouth THEN nose • Dry and Stimulate! • Assess vital signs and perform Apgar • Once infant is stable: • Place skin-to-skin! o Physical assessment o Gestational age assessment o Vitamin K – clotting factors o Erythromycin ointment – eye infection o Parent-infant bonding • Apgar Score – Rate at 1 & 5 minutes  Should repeat Apgar at 10 minutes if the 5 min is < 7 o Score 0, 1 or 2 for each category o A ppearance (Color) o P ulse (Heart Rate) o G rimace (reflex irritability) o A ctivity (muscle tone) o R espiration (Respiratory effort) o MUST know scoring guidelines • • • 0 points • 1 points • 2 points • Activity • Absent • Arms and legs flexed • Active Movement • Pulse • Absent • Below 100 bpm • Over 100 bpm • Grimace • Flaccid • Some flexion of extremities • Active motion (sneeze, cough, pull away) • Appearance (skin color) • Blue, pale • Body pink, extremities blue • Completely pink • Respiration • Absent • Slow, irregular • Vigorous cry • Severely depressed – 0 to 3 • Moderately depressed – 4 to 6 • Excellent condition – 7 to 10 • • Process of Labor – Fourth Stage of Labor • 4th Stage • Period of immediate recovery when homeostasis is established – lasts for 2 hours after placenta is delivered • An important time for observation of complications, such as abnormal bleeding, and a time for maternal-infant bonding. • • Postpartum Patient Assessment • B – Breast • U – Uterus • B – Bladder • B – Bowel • L – Lochia • E – Episiotomy/Laceration/Incision • H – Homan’s sign • E – Emotional state • (don’t forget pain!) • • • ▪ UCs: tocotransducer o Internal Monitoring – mother must be ruptured and at least 2 to 3 cm dilated ▪ Spiral electrode - ▪ IUPC – tells you the frequency, duration, and intensity of contractions • • Portable Telemetry Monitor • Allows woman to ambulate in labor while being continuously monitored • Monica AN24 o Abdominally obtained electronic impulses o Monitors both FHR & UA o 5 electrodes on abdomen o Obtains ECG from maternal & fetal heart o Obtains EMG from uterine muscle o Transmitted via Bluetooth • • Fetal Heart Rate Patterns • Baseline FHR o Average rate during a 10-minute segment that excludes: ▪ Periodic or episodic changes ▪ Periods of marked variability ▪ Segments of the baseline that differ by more than 25 beats/min o Must be at least 2 minutes of interpretable data • Variability o Described as irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater o 4 possible categories of variability: ▪ Absence ▪ Minimal – amplitude range is somewhere between 0 to 5 beats/min; can result from fetal hypoxemia or metabolic academia; congenital anomaly; maybe the mother was given pain medication or CNS depressants; maybe sleeping ▪ Moderate – 6 to 25 bpm; this is what we want; this indicates a well oxygenated baby; a normal fetal acid-base balance ▪ Marked – notify physician • Sinusoidal FHR Pattern – a sign of severe fetal anemia and notify physician • Tachycardia: > 160 beats/min  10 minutes or more o Take a temperature – maybe the mother has an infection; if so, notify the physician o Maybe she was given a medication o Maybe the mother smoked some crack o Give her IV fluids, antibiotics, Tylenol, etc. • Bradycardia: < 110 beats/min  10 minutes or more o Sign that there is a fetal cardiac defect o CMV, maternal hypoglycemia, or maternal hypothermia o Treat the underlying cause • Changes in FHR o Periodic changes occur with UCs o Episodic (nonperiodic changes) not associated with UCs o Accelerations ▪ Caused by dominance of sympathetic nervous system response ▪ An indication of fetal well-being ▪ Highly predictive of a normal fetal acid-base balance ▪ Can be periodic (with a contraction) or episodic (without a contraction) ▪ Visually apparent abrupt increase in FHR above the baseline ▪ > 32 weeks’ gestation  15 x 15 (15 beats above the baseline lasting 15 seconds) ▪ < 32 weeks’ gestation  10 x 10 (10 beats above the baseline lasting 10 seconds) ▪ Can happen when the baby moves, or spontaneously o Decelerations ▪ Caused by dominance of a parasympathetic response ▪ May be benign or abnormal ▪ Categorized as – Early, Late, Variable, or Prolonged ▪ VEAL CHOP ➢ Variable – Cord Compression ✓ Abrupt decrease in heart rate; returns to baseline in 2 minutes ✓ Amnioinfusion (putting fluid back into the uterine cavity so you don't have the cord compression); turn the patient, or give her oxygen ➢ Early Deceleration – Head compression ✓ Correlates with the contraction; lowest part of the deceleration lines up with the peak of the contraction ➢ Acceleration – Oxygenated ➢ Late – Placental insufficiency ✓ At the peak of the contraction the heart rate starts to drop, the contraction is over but the heart rate is still below baseline ✓ Turn Pitocin off, reposition the patient, give her an IV bolus to help maximize the perfusion, may give her oxygen via nonrebreather (8 to 10 L/min) o Prolonged Decelerations ▪ Deceleration of at least 15 bpm from baseline; lasts more than 2 minutes but less than 10 minutes ▪ Cause: Disruption in fetal oxygen supply ▪ From? Prolonged cord compression, sustained head compression, profound uterine placental insufficiency • • FHR Monitoring: Care Management • Nursing management of abnormal patterns o Five essential components of the FHR tracing must be evaluated regularly ▪ Baseline rate, baseline variability, accelerations, decelerations, & changes or trends over time. o If any component is abnormal, corrective measures must be taken immediately to improve fetal oxygenation: intrauterine resuscitation ▪ Supplemental oxygen ▪ Maternal position changes ▪ Increasing intravenous fluids ▪ D/C Pitocin • • Care Management • EFM pattern recognition and interpretation o NICHD Workshop 2008 proposed a three-tier system for EFM interpretation ▪ Category I: normal ▪ Category II: indeterminate ▪ Category III: abnormal o Fetal monitoring standards o Nursing management of abnormal patterns • • Three Tier Classification • Normal FHR patterns  Category I o Baseline FHR in the normal range of 110-160 beats/min o Baseline fetal heart rate variability: moderate o Late or variable decelerations: absent o Early decelerations: may be present or absent o Accelerations either present or absent • Indeterminate FHR patterns  Category II o Bradycardia not accompanied by absent baseline variability o Tachycardia o Minimal or absent baseline variability not accompanied by recurrent decelerations o Marked baseline variability o No accelerations in response to fetal stimulation o Periodic or episodic decelerations • MAXIMIZING COMFORT FOR THE LABORING WOMAN • • Pain During Labor and Birth • Neurologic origins – Visceral and somatic • 1st stage of Labor o Visceral ▪ Cervical changes ▪ Distension of lower uterine segment ▪ Uterine ischemia – lack of blood flow to the uterus o Referred – originates in uterus and radiates to the abdominal wall, lumbosacral area of the back, iliac crests, gluteal area, thighs and lower back. o Pain impulses during the first stage of labor are transmitted via the T1 to T12 spinal nerve segment and accessory lower thoracic and upper lumbar sympathetic nerves. • 2nd stage of Labor o Somatic – described as intense, sharp, burning, and well localized ▪ Stretching and distention of perineal tissues & pelvic floor ▪ Distention & traction on peritoneum & uterocervical supports during contractions ▪ Pressure against the bladder and rectum o Lacerations of soft tissues – cervix, vagina, perineum o Expulsive forces and pressure exerted by presenting part on bladder, bowel, pelvic structures • • Pain During Labor and Birth • Perception of Pain o Pain threshold o Pain tolerance – the level of pain a laboring woman is willing to endure ▪ Influenced by: her desire for a natural, vaginal birth; her preparation for childbirth; her level of anxiety; the nature of her support during labor; and her willingness and ability to participate in nonpharmacologic measures for comfort • Expression of Pain o Physiologic ▪ Increased catecholamine levels ▪ BP and HR increase ▪ Maternal respiratory patterns change in response to an increase in oxygen consumption ▪ Pallor and diaphoresis ▪ Gastric acidity increases o Sensory o Emotional ▪ Increasing anxiety ▪ Writhing, Crying, Groaning, Gesturing and excessive muscular excitability • Factors influencing pain perception and response o Physiologic factors ▪ Uterine contractions, cervical dilation, and effacement are important aspects of labors, and can be the cause of discomfort or pain ▪ Beta-endorphins are endogenous opioids secreted by the pituitary gland that act on central and peripheral nervous systems to reduce pain  associated with feelings of euphoria and analgesia o Culture ▪ Chinese woman may not exhibit reactions to pain, although exhibiting pain during childbirth is acceptable. They consider accepting something when it is first offered as impolite; therefore, pain interventions must be offered more than once. Acupuncture may be used for pain relief ▪ Arab or Middle Eastern women may be vocal in response to labor pain. They may prefer medication for pain relief ▪ Japanese women may be stoic in response to labor pain but they may request medication when pain becomes severe ▪ South Asian women may endure severe pain before requesting relief ▪ Hispanic women may be stoic until late in labor, when they may become vocal and request pain relief ▪ Native-American women may use medications or remedies made form indigenous plants. They are often stoic in response to labor pain ▪ African-American women may express pain openly. Use of medication for pain relief varies. o Anxiety – Fear-Tension-Pain cycle – causes catecholamine release which increases stimuli to the brain, decreased blood flow, increased tension, and more pain ▪ As anxiety and fear heighten, muscle tension increases, the effectiveness of uterine contractions decreases, the experience of discomfort increases, and a cycle of increased fear and anxiety begins o Previous experience ▪ Sensory labor pain for nulliparous women is often greater than for multiparous women during early labor because their reproductive tract structures are less flexible ▪ Parity may affect the perception of labor pain because nulliparous women often have longer labors and therefore greater fatigue o Comfort – View labor as a natural process o Support o Environment o Gate-Control Theory of Pain ▪ Pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time ▪ Using distraction techniques such as massage or effleurage, stroking, music, focal points, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain ▪ Distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain ▪ The main impetus behind the gate-control theory as it relates to pain is to introduce the brain to a positive stimulus by using all of the five senses ▪ Stimulating the senses will not create a pain-free environment, but it can help decrease the discomforts of labor o Nurse is vital in promoting positive birth experience • • Nonpharmacologic Pain Management • Provide the woman with a sense of control over her childbirth as she makes choices about the measures that are best for her • Allow normal course of labor to progress more efficiently, as opposed to pharmacologic methods, which tend to interrupt or even show the labor process • Childbirth preparation methods o Methods: ▪ LaMaze (breathing techniques; external focus – taught to focus on something they brought in with them; getting the patient to the point when she wants epidural) ▪ Bradley (visualizing their cervix open up, internal focus; do not want medication, in their birth plan they don't want you to offer them medications) o Birth philosophy – Birth plan • • Focusing And Relaxation Techniques • Attention-focusing & Distraction – bring a favorite object from home or focus on an object in the room • Imagery – focuses her attention on a pleasant scene, a place where she feels relaxed, or an activity she enjoys • Feedback – “relax” – the woman and her coach say this word at the onset of each contraction and throughout if needed • Herbal teas – can help them relax (chamomile), reduce nausea (lemon balm, peppermint), and enhance energy and reduce fatigue (ginger, ginseng); may benefit by maintaining fluid balance • Relaxation – increases oxygenation to the uterus, thus increasing oxygenation to the baby • Helps bring catecholamines down • • Breathing Techniques • Always – begin and end with deep breath • Paced breathing techniques – Box 17-3, p. 387 o Cleansing Breath – relaxed breath in through nose and out through mouth; used at the beginning and end of each contraction o Slow Paced Breathing (approximately 6 to 8 breaths per minute) ▪ Performed at approximately half the woman’s normal breathing rate and is initiated when she can no longer walk or talk through contractions o Modified-Paced Breathing (Approximately 32 to 40 breaths per minute) ▪ Performed at about twice the normal breathing rate (number of breaths per minute multiplied by 2) ▪ IN-OUT/IN-OUT/IN-OUT… ▪ For more flexibility and variety, the woman may combine the slow and modified breathing by using the slow breathing for beginnings and ends of contractions and modified breathing for more intense peaks. This technique conserves energy, lessens fatigue, and reduces risk for hyperventilation. o Pattern-Paced or Pant-Below Breathing (same Rate as Modified) ▪ Enhances concentration ▪ 3:1 patterned breathing  IN-OUT/IN-OUT/IN-OUT/IN-BLOW ▪ 4:1 patterned breathing  IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW o Transition o Urge to push • • Other Nonpharmacologic Pain Management • Effleurage – Light rhythmic stroking o Light stroking, usually of the abdomen, in rhythm with breathing during contractions; used to distract the woman from contraction pain • Touch & massage o Therapeutic touch uses the concept of energy fields within the body called prana o TT uses laying-on of hands by a specially trained person to redirect energy fields associated with pain o Head, hand, back, and foot massage may be very effective in reducing tension and enhancing comfort o Combining massage with aromatherapy oil or lotion enhances relaxation both during and between contractions • Music o Can be used to promote relaxation in early labor and to stimulate movement as labor progresses. o Can help create a more relaxed atmosphere in the birth room, leading to a more relaxed approach by the healthcare providers • Biofeedback o Based on the theory that if a person can recognize physical signals, certain internal physiologic evens can be changed o Informational biofeedback helps couples develop awareness of their bodies and use strategies to change their responses to stress o Formal biofeedback, which uses machines to detect skin temperature, blood flow, or muscle tension, also can prepare women to intensify their relaxation responses • Aromatherapy – essential oils, lavender on the pillow o Lavender, rose and jasmine oils can promote relaxation and reduce pain o Rose oil also acts as an antidepressant and uterine tonic, and jasmine oil strengthens contractions and decreases feelings of panic in addition to reducing pain • Counterpressure – using your fist or the heel of your hand and putting pressure where the baby is laying o Teach to the significant other so they can help o Steady pressure applied by a support person to the sacral area with a firm object or the fist or heel of the hand. o Lifts the occiput off these nerves, thereby providing pain relief. • Birthing ball – make sure there is someone behind them or around for support so they don't fall; equalizes pressure and is also helpful for an occiput posterior baby • • Application of Heat and Cold • Heat o Increases blood flow to the area of discomfort o Relieves muscle ischemia o Effective for back pain caused by a posterior position or general backache from fatigue • Cold cloths o To cool down • • Anesthesia encompasses analgesia, amnesia, relaxation, and reflex activity  abolishes pain perception by interrupting the nerve impulses to the brain • Analgesia: the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness • • The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned • First Stage • Opioid agonist analgesics • Opioid agonist-antagonist analgesics • Epidural (block) analgesia • Combined spinal-epidural (CSE) analgesia • Nitrous Oxide • Second Stage • Nerve block analgesia and anesthesia (local infiltration anesthesia, pudendal block, spinal anesthesia, epidural analgesia, CSE analgesia) • Nitrous oxide • Vaginal Birth • Local infiltration anesthesia • Pudendal block • Epidural (block) anesthesia and analgesia • Spinal (block) anesthesia • CSE analgesia and anesthesia • Nitrous Oxide • Cesarean Birth • Spinal (block) anesthesia • Epidural (block) anesthesia • General anesthesia • • • Systemic Analgesia • Route: IV, IM or IV PCA (woman self-administers small does of an opiod analgesic by using a pump) • Readily cross placenta • Opioid (narcotic) agonists o Dilaudid, Demerol, Sublimaze, Sufenta o Provide sedation and euphoria, but their analgesic effect in labor is limited o Used cautiously in women with cardiovascular/respiratory problems o Meperidine hydrochloride is a synthetic opioid that is the most widely used systemic medication for labor pain o Cross the placenta and causes prolonged neonatal sedation and neurobehavioral changes – cannot be reversed with naloxone • Opioid (narcotic) agonist-antagonist o Butorphanol (Stadol), Nalbuphine (Nubain) o Provide adequate analgesia without causing significant respiratory depression in the mother or neonate • Opioid (narcotic) antagonist o Narcan – To reduce excessive CNS depression from opioid agonists; reverses any effects of these drugs o Woman should be told that the pain that was relieved with the use of the opioid analgesic will return with the administration of the opioid antagonist • • Opioid Antagonist • Adverse effects – maternal hypotension and hypertension, tachycardia, hyperventilation, nausea and vomiting, sweating, tremulousness • ALWAYS read label to verify adult versus neonatal drug concentrations • If given to a woman who is opiate dependent, pain will return suddenly – they need to have more • • Nursing Intervention in Pain Management in Labor * Maintaining patient safety while administering analgesics Ss AS o The woman should be observed for alteration in vital signs, pallor, clammy skin, and leakage of CSF for 1 to 2 hours after the blood patch is performed • • Local/Pudendal Anesthesia • Local – administered in perineum; adequate for episiotomy and perineal repair • Pudendal – administered in vagina; adequate anesthesia for episiotomy, forceps, vacuum, episiotomy repair • Both administered in second stage labor*** • Xylocaine, Procaine, Marcaine, Nesacaine, Carbocaine • • Spinal Anesthesia (Block) • Contains local only or may be in combination with opioid agonist (fentanyl) • Injected into the subarachnoid space and mixes with CSF • For elective C/S • May be used for vaginal birth (not for labor) • • Epidural anesthesia/analgesia – creates a block so they can actively participate in birth • Lumbar epidural anesthesia/analgesia o Bupivacaine (Marcaine) or Ropivicaine o Injected into epidural space with insertion of epidural catheter o Catheter connected to continuous pump or PCA pump o For relief of pain of uterine contractions and birth (vaginal or cesarean) o Advantages – can actively participate in labor, feels like she has control o Disadvantages – can’t empty her bladder • Combined spinal-epidural analgesia – spinal works quickly, and epidural kicks in and lasts through labor o Needle in subarachnoid space using fentanyl and bupivacaine (Marcaine) o Faster onset of action, synergistic effect of opioids and local anesthesia, lower total dose of required medication reduces motor blockade response o Same advantages as lumbar epidural but in addition, woman feels vaginal and rectal pressure and is usually able to push • Epidural and intrathecal opioids o Woman feels contractions but not pain o Fetanyl, sufentanil, or preservative-free morphine can be used o More common indication for the administration of epidural or intrathecal analgesics is the relief of postoperative pain • Contraindications to epidural blocks – rod in their back, or an allergy • Epidural effects on the newborn • Disadvantages and Side Effects o Ability to move freely and to maintain control of labor limited, related to degree of anesthesia and use of other medical interventions, i.e. continuous monitoring, IV, IV pump) o Vasodilation and hypotension, bladder distention, unequal uptake of medication, pruritis, shivering. • • Nursing Role – Spinal/Epidural • Review prenatal history for any contraindications to epidural or spinal anesthesia • Check for signed informed consent • Review prenatal labs, especially CBC and platelets • Review maternal vital signs and FHR before and after administration • Pre-load with 1000-2000 cc’s Lactated Ringers • Assist patient into position and support during administration • Monitor vital signs and FHR q 5 minutes post administration; be alert to hypotension • • Nursing Role After Administration • Position patient to prevent supine hypotension • Monitor IV rate as specified • Monitor FHR rate, especially if maternal hypotension is present • Insert Foley catheter, or monitor bladder for distension if Foley not used • Administer IV vasopressor (Ephedrine 5-10 mg) if needed • Keep MD/midwife informed of patient status • • Contraindications to Spinal and/or Epidural • Active or anticipated maternal hemorrhage • Maternal hypotension • Antiocoagulant therapy or bleeding disorder • Infection at the injection site • Increased ICP caused by mass lesion • Allergy to the anesthetic drug • Maternal refusal or inability to cooperate • Some types of maternal cardiac conditions • Some types of previous spinal surgeries • • Nitrous Oxide • Patient controlled analgesia • May be used in first and second stage of labor • Administered in combination with oxygen o Low dose (50% or less nitrous) o Promotes relaxation o Sense of control o Reduces perception of pain • Administration o Via mask or mouthpiece (pt holds) o Inhale with contraction only o Remove when contraction subsides • Scavenging equipment • Observe/assess for: N&V, dizzines, drowsiness • • Pharmacologic Pain Management • General anesthesia o Only used in extreme emergent cases o Readily crosses placenta – anticipate neonatal resuscitation o Wedge to displace uterus o Sodium citrate/citric acid (Bicitran) o Famotidine (Pepcid) or ranitidine (Zantac) prior to a c-section o Metoclopramide Reglan) o Risk for fetal exposure à neonatal narcosis o NPO and IV infusion must be in place o Succinylcholine is administered to facilitate passage of an endotracheal tube • • Important Terms • Gravidity o Gravida: woman who is pregnant o Gravidity: pregnancy o Multigravida: woman who has had two or more pregnancies o Multipara: woman who has completed two or more pregnancies to stage of fetal viability o Nulligravida: woman who has never been pregnant o Primigravida – pregnant for the first time • Parity o Parity: number of pregnancies in which fetus or fetuses have reached viability, not the number of fetuses born o Nullipara: woman who has not completed pregnancy with a fetus or fetuses who have reached the stage of fetal viability o Primipara: A woman who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks of gestation o Multipara: A woman who has completed two or more pregnancies to 20 weeks of gestation or more • Gestational Age of Pregnancy o Preterm: a pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation o Late preterm: a pregnancy that has reached between 34 weeks 0 days and 36 weeks 6 days of gestation o Early term: a pregnancy that has reached between 37 weeks 0 days and 38 weeks 6 days of gestation o Full term: a pregnancy that has reached between 39 weeks 0 days and 40 weeks 6 days of gestation o Late term: a pregnancy that has reached between 41 weeks 0 days and 41 weeks 6 days of gestation o Post term: a pregnancy that has reached between 42 weeks 0 days and beyond of gestation • • GTPAL System • G = Gravidity • T = Term (37-42 weeks) • P = Preterm birth (20-366 weeks) • A = Abortion (less than 20 weeks) • L = Living Children • G/P System o G = Gravida o P = Para (birth after 20 weeks) • • Example GTPAL System • Woman who is pregnant now and has two children, one born at 38 weeks and one at 42 weeks. • Woman who recently gave birth to twin boys at 34 weeks. (G1T0P1A0L2) • • Pregnancy Tests • Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy o Production begins as early as day of implantation o Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses • Many pregnancy tests available • • • Signs of Pregnancy • Presumptive: those changes felt by the woman (e.g., amenorrhea, fatigue, breast changes) • Probable: those changes observed by an examiner (e.g., Hegar sign, ballottement, pregnancy tests) • Positive: those signs attributed only to the presence of the fetus (e.g., hearing fetal heart tones, visualizing the fetus, palpating fetal movements) • • Anatomical and Physiologic Adaptations to Pregnancy – Reproductive Systems and Breasts • Uterus • Moves from pelvic to abdominal organ at 12 weeks • Changes in size, shape, and position • Fundus at level of umbilicus at 20 weeks – o 20 weeks gestation = 20 centimeters o Grows one centimeter each week • Changes in contractility – increases after 4th month (Braxton Hicks contractions) • Uteroplacental blood flow – increases 20 fold • Hegar sign (6 wks) – softening of the uterine isthmus • Quickening (16-20 wks) – first fetal movements felt by mother • Ballottement (16-18 wks) movability of floating fetus; HCP can feel fetus move away and float back when tapped • Braxton-Hicks • Lightening – (38-40 wks) – fundal height decreases as fetus descends into pelvis • • Internal Ballottement • • Vagina, Vulva, and Cervix • Chadwick sign (6-8 wks) – bluish color of cervix and vagina • Goodell sign (5-6 wks) – softening of cervical tip • Leukorrhea – Increased whitish vaginal discharge • Friability of cervix – tissue is easily damaged • • Breasts • Increases levels of estrogen and progesterone à Breasts become larger and fuller • Hypertrophy of Montgomery’s tubercles (oil glands in areola) • Increase in pigmentation of areola • May see dilated blood vessels under skin • Precolostrum – clear thin viscous liquid–12 wk • Colostrum can see seen by 16 weeks pregnancy (white/creamy/orange color) • • Anatomical and Physiologic Adaptations to Pregnancy – General Body Systems • • Cardiovascular System • Slight hypertrophy of heart • Increased blood volume (1500 cc) or 40-50% • Plasma increases faster than RBCs causing physiologic anemia • Increased C.O. 30-50% • Systolic murmur common during pregnancy • B/P same in 1st and 3rd trimester, slight decrease in 2nd by 5-10 mm Hg • Compression of vena cava – Supine hypotensive syndrome/vena caval syndrome • Compresson of iliac veins & inferior vena cava à reduced blood flow to legs o Dependent edema o Varicose veins (legs & vulva) o Hemorrhoids • Hypercoagualibility during pregnancy • • Respiratory System • Increased metabolic rate • Increased need for oxygen (infant, size of breasts, uterus, etc.) • Estrogen à ligaments in rib cage to relax à increased chest expansion • Estrogen à congestion/increased vascularity in upper respiratory tract à nasal stuffiness, epistaxis, ear aches • Elevation of diaphragm: thoracic breathing, increased sensitivity to CO2, dyspnea - may need to sleep with more pillows, more upright • • Renal System • Pressure on the bladder by the growing uterus during the 1st & 3rd trimesters leads to urinary frequency, urgency, & nocturia • Glomerular filtration rate & renal plasma flow are increased by 50% by 2nd trimester causing slight spillage of protein ▪ Second: weeks 14-26 ▪ Third: weeks 27-40 • • Diagnosis of Pregnancy • Signs of Pregnancy o Presumptive – reported by woman o Probable – detected by examiner o Positive – Attributed to fetus • • Estimating Date of Birth • Estimated date of birth (EDB) • Older terms o Estimated date of delivery (EDD) o Estimated date of confinement (EDC) • Ultrasound – Standard procedure for determining the gestational age of the fetus • • Determination of Due Date – EDC or EDD • Naegele’s Rule o Start with first day of last normal menstrual period o Subtract 3 months o Add 7 days o Add year if appropriate o Example, LMP of April 20th; What is the EDC?  January 27 • Adaptation to Pregnancy • Maternal adaptation o Accepting the pregnancy o Identifying with the mother role o Reordering personal relationships o Establishing relationship with fetus: attachment process of the mother ▪ Phase 1: She accepts the biologic fact of pregnancy ▪ Phase 2: She accepts the growing fetus as distinct from herself ▪ Phase 3: She prepares realistically for the birth and parenting of the child o Preparing for childbirth • Paternal adaptation  Accepting the pregnancy  Couvade syndrome o Developmental tasks experienced by the expectant father ▪ Announcement phase ▪ Moratorium phase ▪ Focusing phase o Identifying with the father role o Reordering personal relationships o Establishing relationship with the fetus o Preparing for birth • Adaptation to parenthood for the non-pregnant partner • Sibling adaptation  Depends on age and dependency needs • Grandparent adaptation • • Models of Prenatal Care • Traditional: o First visit in first trimester o Monthly visit until week 28 o Bimonthly visit week 28-36 o Weekly visit 36th week until birth • Centering Pregnancy o Uses group modality for instruction o Individual patient involvement & interaction • o At risk for iron deficiency anemia R/T increase iron requirements o May start taking at 12 weeks • • Follow-Up Visits – Maternal Assessmens • VS, weight gain, urine screen for protein &/or glucose, edema • Uterine contractions, pain/pressure • Vaginal discharge/bleeding • One-hour glucose screen 24-28 wks, followed by GTT if abnormal • GBS screen at 35-37 wks • Repeat RTI testing prn & DV Screening • • • Follow-Up Visits – Assessments of the Fetus • Fetal Heart Rate (FHR) 110-160/min • Fundal Height (1 cm/week gestation in second trimester) • Fetal Movement: o Quickening o Kick count o Changes in fetal movement • Fetal Position (Leopold maneuvers or U/S) • Ultrasound (gestational age) prn • • RhoGAM Workup for Rh Negative Mothers • At 28 weeks, the mother is sent for a work-up to be sure she has not formed antibodies (become sensitized) to the Rh factor (Coombs’ test). • If she is negative for antibodies she will receive an Rh immune globulin injection (RhoGAM, Rhophylac) • This is also given to Rh negative mothers who have had a miscarriage, abortion, ectopic pregnancy, CVS, amniocentesis, version, or abdominal trauma. • • Pregnancy Counseling/Teaching • Danger Signs/Complications (p. 342) • Discomforts of Pregnancy (pp. 354-355) • Emotional Changes • Smoke-free environment • Domestic Violence* • Birth Plan* • Infant Care Decisions: pediatrician, breast or bottle, circumcision • • Effect of Domestic Violence on Developing Baby • Miscarriage • Preterm birth • IUGR (poor maternal nutrition) • Maternal self-medicating with alcohol/drugs • Delayed prenatal care • • Effects of DV on Pregnant Women • Death – increased risk of physical and emotional abuse • Injury (especially to breasts/uterus) • Placenta abruption • Sexual abuse • RTI • Poor nutrition/substance abuse • Isolation • Delayed prenatal care • Insomnia, stress, difficult to relax • • Routine Antenatal Screening for Domestic Violence (IPV) • Assess every prenatal woman at every visit • Should be a private area – no partner or children should be present • Women usually prefer female nurse • Ask about relationship, violence, etc. Can use standard form • Required Reporting • Gunshot injuries • Victim is a child • Victim states she intends on killing abuser • • DV (IPV) Safety Plan • Develop one if in danger. Most dangerous time is after woman leaves abuser • Call 911 if in danger. Have sign for neighbors to call police • Include: o Bag of clothes o Resources o Money, keys, extra documents o Place to stay • • Danger Signs of Pregnancy – Signs of Potential Complications • First Trimester o Severe vomiting o Abdominal cramping/pain; vaginal bleeding o Symptoms of infection • Second/Third Trimester - the list above and: o Change in fetal movement o Visual disturbance, swelling in face, fingers, sacrum, severe H/A, convulsions, epigastric pain o Gylosuria, positive GTT reaction o Sudden discharge of fluid from vagina before 37 weeks • • Common Discomforts of Pregnancy – Table 14-2 • Urinary frequency • Fatigue and sleep problems • Nausea & vomiting* o Wet/Dry Diet o Avoid greasy foods/fat o Dry carbohydrates 30 minutes prior to onset of N/V or crackers before getting out of bed o Avoid drinking excessive amounts of fluid o Eat small frequent meals o Avoid skipping meals o Some herbal teas good (peppermint) o If excessive, could be hyperemesis gravidarum . • Heartburn* o Caused by reflux of gastric contents in esophagus o Small frequent meals o Wet/Dry diet so stomach not distended o Sit up after meals (don’t lie down for at least one hour) o Avoid tight clothes across abdomen • Constipation* o Decreased motility and iron supplements predisposes pregnant woman to constipation o Increase fiber in diet (28 grams/day) o Whole wheat products, fruits & vegetables • Hospital o Labor, delivery, recovery rooms (LDRs) o Labor, delivery, recovery, postpartum rooms (LDRPs) • Birth centers • Home birth o Remains a controversial topic in American health care • • Development of Birth Plan • Who will deliver infant? • Where will infant be delivered? Labor support? • Natural vs. Managed Labor o Spontaneous labor or scheduled induction o Pain management • Breast or bottle feeding • Circumcision • Tubal ligation • • Maternal and Fetal Nutrition • • My Plate • Increased emphasis on vegetables and fruit filling the plate balanced with grains and protein.\ • Note the serving of dairy • • Nutrient Needs Before Conception • Healthy diet ensures adequate nutrients for developing fetus • Folic acid intake • 0.6 mg (600 micrograms) in fortified foods recommended. • Neural tube defects can occur with poor intake • Desirable body weight reduces maternal and fetal risks • • Recommendations for Daily Intakes for Pregnant Women (Table 15-1) • Energy (Kilocalories) Variable • Protein – 71 g (2nd/3rd trimester) • Fiber – 28 g • Iron – 30 mg • Folic Acid – 600 mcg • Calcium – 1300/1000 mg • • Recommended Weight Gain • Normal BMI: 11.5 - 16 kg  (25-35#) • Low BMI: 12.5 - 18 kg  (28-40#) • Overweight: 7 - 11.5 kg  (15-25#) • Obese: 5 - 9 kg  (11-20#) • Adolescent: Upper range of scale to meet own growth needs • Twin gestation: 17 – 25 kg  (37-54#) (normal BMI) • • Food Recommendations • Foods to encourage: increase protein, calcium, iron and folic acid • Foods to avoid: Shark, swordfish, sushi, raw cookie dough, soft cheeses, raw eggs • Limit the following foods: Low mercury fish & shellfish • • Pattern of Weight Gain • Need to gain weight throughout pregnancy • First Trimester o Maternal tissue primarily o Total: 1-2 kg (2-5 pounds) o No additional kcal needed over prepregnancy • Second & Third Trimester o Maternal tissue primarily 2nd; 3rd primarily fetus o 0.4 kg/week (normal BMI) o Additional 340-452 kcal/day recommended 2nd/3rd trimesters • • Other Issues • Pica • Food Cravings • • Pica – Commonly Ingested Nonfood Substances • Pica is the ingestion of non-nutritive substances • Dirt, clay, dry laundry starch • Others: ice, hair, gravel, charcoal, antacid tablets, baking soda, coffee grounds, inner tubes • Often displaces more nutritious foods in the diet • • Other Nutritional Issues During Pregnancy • Adolescent pregnancy needs focus on improving o Nutrition knowledge o Meal planning o Food preparation o Access to prenatal care o Nutritional interventions o Educational programs • Physical activity during pregnancy o Factors to consider prior to exercise ▪ Dehydration ▪ Calorie intake • • Care Management • Assessment o Obstetric and gynecologic effects on nutrition o Diet history o Health history o Usual maternal diet o Physical examination ▪ Anthropometric (body) measurements o Laboratory testing ▪ Anemia • • Nutritional Care and Teaching • Programs for women with limited financial resources o SNAP o WIC • Daily food guide and menu planning o MyPlate program • Food safety