Maternal Assessment During Labor and Birth, Exams of Nursing

Download Maternal Assessment During Labor and Birth and more Exams Nursing in PDF only on Docsity! MATERNAL ASSESSMENT DURING LABOR AND BIRTH Nurs 11 mgt in labor and birth notes • VS • Review prenatal record for r/f of decrease in uteroplacental circulation • Pelvic exam (if no blood is present) or us to assess dilation • Evaluate pain & effectiveness of pain mgmt. during regular intervals Vaginal Examination Purpose is to assess dilation, effacement, membrane status, fetal presentation, position, station & degree of head flexion & presence of fetal skull swelling or molding. Cervical Dilation and Effacement The width of the cervical opening determines dilation, and the length of the cervix assesses effacement. Effacement and dilation are used to assess cervical changes as follows: Effacement: • 0%: cervical canal is 2 cm long • 50%: cervical canal is 1 cm long • 100%: cervical canal is obliterated Dilation: • 0 cm: external cervical os is closed • 5 cm: external cervical os is halfway dilated • 10 cm: external os is fully dilated and ready for birth passage Rupture of Membranes When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged ruptured membranes increase the risk of infection as a result of ascending vaginal pathologic organisms for both mother and fetus. Signs of intrauterine infection to be alert for include maternal fever, fetal and maternal tachycardia, foul odor of vaginal discharge, and an increase in white blood cell count. The fetal membranes usually rupture during the first stage of labor. To confirm if they have ruptured, a sample of fluid is taken from the vagina via a nitrazine yellow dye swab to determine the fluid’s pH. Vaginal fluid is acidic, while amniotic fluid is alkaline and turns a nitrazine swab blue. Sometimes, however, false-positive results can occur, especially in women experiencing a large amount of bloody show because blood is alkaline. The membranes are most likely intact if the nitrazine swab remains yellow to olive green with pH between 5 and 6. The membranes are probably ruptured if the nitrazine swab turns a blue-green to deep blue with pH ranging from 6.5 to 7.5 Assessing Uterine Contractions The contraction resembles a wave, moving downward to the cervix and upward to the fundus of the uterus. Each contraction starts with a building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement) Assessment of the contractions includes frequency, duration, intensity, and uterine resting tone (see Chapter 13 for a more detailed discussion). Uterine contractions with an intensity of 30 mm Hg or greater initiate cervical dilation. During active labor, the intensity usually reaches 50 to 80 mm Hg. Resting tone is normally between 5 and 10 mm Hg in early labor and between 12 and 18 mm Hg in active labor. 2 To palpate the fundus for contraction intensity, place the pads of your fingers on the fundus and describe how it feels: like the tip of the nose (mild), like the chin (moderate), or like the forehead (strong). Palpation of intensity is a subjective judgment of the indentability of the uterine wall; a descriptive term is assigned (mild, moderate, or strong) Performing Leopold Maneuvers Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the nurse’s hands with the fingers together palpate the uterus. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question: • Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? • Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) • Maneuver 3: What is the presenting part? • Maneuver 4: Is the fetal head flexed and engaged in the pelvis? Purpose: To Determine Fetal Presentation, Position, and Lie Place the woman in the supine position and stand beside her. 1. Perform the first maneuver to determine presentation. • Facing the woman’s head, place both hands on the abdomen to determine fetal position in the uterine fundus. • Feel for the buttocks, which will feel soft and irregular (indicates vertex presentation); feel for the head, which will feel hard, smooth, and round (indicates a breech presentation). 2. Complete the second maneuver to determine position. • While still facing the woman, move hands down the lateral sides of the abdomen to palpate on which side the back is located (feels hard and smooth). • Continue to palpate to determine on which side the limbs are located (irregular nodules with kicking and movement). 3. Perform the third maneuver to confirm presentation. • Move hands down the sides of the abdomen to grasp the lower uterine segment and palpate the area just above the symphysis pubis. • Place thumb and fingers of one hand apart and grasp the presenting part by bringing fingers together. • Feel for the presenting part. If the presenting part is the head, it will be round, firm, and ballottable; if it is the buttocks, it will feel soft and irregular. 4. Perform the fourth maneuver to determine attitude. • Turn to face the client’s feet and use the tips of the first three fingers of each hand to palpate the abdomen. • Move fingers toward each other while applying downward pressure in the direction of the symphysis pubis. If you palpate a hard area on the side opposite the fetal back, the fetus is in flexion, because you have palpated the chin. If the hard area is on the same side as the back, the fetus is in extension, because the area palpated is the occiput. 5 In external or indirect monitoring, two ultrasound transducers, each of which is attached to a belt, are applied around the woman’s abdomen. They are similar to the handheld Doppler device. One transducer is called a tocotransducer, a pressure-sensitive device that is applied against the uterine fundus. It detects changes in uterine pressure and converts 6 the pressure registered into an electronic signal that is recorded on graph paper. The tocotransducer is placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions. The other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations. It is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. CONTINUOUS INTERNAL MONITORING Continuous internal monitoring is usually indicated for women or fetuses considered to be at high risk. Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, or medical conditions such as diabetes or hypertension. It involves the placement of a spiral electrode into the fetal presenting part, usually the parietal bone on the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions (Fig. 14.6). The fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus. Specially trained labor and birth nurses are permitted to place the spiral electrode on the fetal head when the membranes rupture to assess the FHR in some health care facilities, but they do not place the intrauterine pressure catheter in the uterus. Internal monitoring does not have to include both an intrauterine pressure catheter and a scalp electrode. A fetal scalp electrode can be used to monitor the fetal heartbeat without monitoring the maternal intrauterine pressure. Both the FHR and the duration and interval of uterine contractions are recorded on the graph paper. This method permits evaluation of baseline heart rate and changes in rate and pattern. Four specific criteria must be met for this type of monitoring to be used: • Ruptured membranes • Cervical dilation of at least 2 cm • Presenting fetal part low enough to allow placement of the scalp electrode • Skilled practitioner available to insert spiral electrode Compared with external monitoring, continuous internal monitoring can accurately detect both short-term (moment-to- moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias. In addition, maternal position changes and movement do not interfere with the quality of the tracing. BASELINE FHR Baseline fetal heart rate refers to the average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes. The normal baseline FHR ranges between 110 and 160 beats per minute (bpm). The normal baseline FHR can be obtained by auscultation, ultrasound, or Doppler, or by a continuous internal direct fetal electrode. Category I: normal Predictive of normal fetal acid–base status and do not require intervention • Baseline rate (110–160 bpm) • Baseline variability moderate • Present or absent accelerations • Present or absent early decelerations • No late or variable decelerations • Can be monitored with intermittent auscultation during labor Category II: indeterminate 7 Not predictive of abnormal fetal acid–base status, but require evaluation and continued surveillance 10 FHR variability is an important clinical indicator that is predictive of fetal acid–base balance and cerebral tissue perfusion. It is influenced by fetal oxygenation status, cardiac output, and drug effects. As the CNS is desensitized by hypoxia and acidosis, FHR decreases until a smooth baseline pattern appears. Loss of variability may be associated with a poor outcome. PERIODIC BASELINE CHANGES Periodic baseline changes are temporary, recurrent changes made in response to a stimulus such as a contraction. The FHR can demonstrate patterns of acceleration or deceleration in response to most stimuli. Fetal accelerations are transitory abrupt increases in the FHR above the baseline that last less than 30 seconds from onset to peak. They are associated with sympathetic nervous stimulation. They are visually apparent, with elevations of FHR of more than 15 bpm above the baseline, and their duration is longer than 15 seconds but less than 2 minutes. They are generally considered reassuring and require no interventions. Accelerations denote fetal movement and fetal well-being and are the basis for nonstress testing. Responding to Fetal Heart Rate Distress during Labor During possible fetal distress that involves lack of variability, late decelerations, and fetal tachycardia, simply changing the woman’s position is inadequate. The nurse should notify the health care provider immediately regarding the situation. Early decelerations are visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They rarely decrease more than 30 to 40 bpm below the baseline. Typically, the onset, nadir, and recovery of the deceleration occur at the same time as the onset, peak, and recovery of the contraction. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Early decelerations are not indicative of fetal distress and do not require intervention. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. They have a gradual waveform and can be recurrent, occurring with each contraction over a period of time. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists. Conditions that may decrease uteroplacental perfusion with resultant decelerations include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia. Recurrent or intermittent late decelerations are always category II (indeterminate) or category III (abnormal) regardless of depth of deceleration. Acute episodes with moderate variability are more likely to be correctable, while chronic episodes with loss of variability are less likely to be correctable. Box 14.1 highlights interventions for category III decelerations.. Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be of a U, V, or W, or they may not resemble other patterns. Variable decelerations usually occur abruptly with quick deceleration. They are the most common deceleration pattern found in the laboring woman and are usually transient and correctable. Variable decelerations are associated with cord compression. However, they are classified either as category II or III depending on the accompanying change in baseline variability. The pattern of variable 11 deceleration consistently related to the contractions with a slow return to FHR baseline warrants further monitoring and evaluation. Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes. The rate usually drops to less than 90 bpm. Many factors are associated with this pattern, including prolonged cord compression, abruptio placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, 12 maternal seizures, regional anesthesia, or uterine rupture. Prolonged decelerations can be remedied by identifying the underlying cause and correcting it. Interventions for Category III Patterns • Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. • Discontinue oxytocin or other uterotonic agent as dictated by the facility’s protocol if it is being administered. • Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression. • Administer oxygen via nonrebreather face mask to increase fetal oxygenation. • Increase the IV fluid rate to improve intravascular volume and correct maternal hypotension. • Assess the client for any underlying contributing causes. • Provide reassurance that interventions are to effect pattern change. • Modify pushing in the second stage of labor to improve fetal oxygenation. • Document any and all interventions and any changes in FHR patterns. • Prepare for an expeditious surgical birth if the pattern is not corrected in 30 minutes. A sinusoidal pattern is described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for more than 20 minutes. A true sinusoidal FHR pattern is rare. It is attributed to a derangement of CNS control of FHR and occurs when a severe degree of hypoxia secondary to fetal anemia and hypovolemia is present. It is always considered a category III pattern, and to correct it, a fetal intrauterine transfusion would be needed. It indicates the fetus is in marked jeopardy. Combinations of FHR patterns obtained by EFM during labor are not infrequent. Category II and III patterns are more significant if they are mixed, persist for long periods, or have frequent prolonged late decelerations, absent or minimal variability, bradycardia or tachycardia, and prolonged variable decelerations lower than 60 bpm. The likelihood of fetal compromise is increased if category II and III patterns are associated with decreased baseline variability or abnormal contraction patterns. Other Fetal Assessment Methods In situations suggesting the possibility of fetal compromise, such as category II or III FHR patterns, further ancillary testing such as umbilical cord blood analysis and fetal scalp stimulation may be used to validate the FHR findings and assist in planning interventions. Umbilical Cord Blood Analysis Neonatal and childhood mortality and morbidity, including cerebral palsy, are often attributed to fetal acidosis as indicated by a low cord pH at birth. Umbilical cord blood acid–base analysis drawn at birth provides an objective method of evaluating a newborn’s condition, identifying the presence of intrapartum hypoxia and acidemia. This test is considered a good indicator of fetal oxygenation and acid–base condition at birth. The normal mean pH value range is 7.2 to 7.3. The pH values are useful for planning interventions for the newborn born with low 5-minute Apgar scores, severe fetal growth restriction (FGR), category II and III patterns during labor, umbilical cord prolapse, uterine rupture, maternal fever, placental abruption, meconium-stained amniotic fluid, and post-term births. The interventions needed for the compromised newborn might include providing an optimal extrauterine environment, fluids, oxygen, medications, and other treatments. Fetal Scalp Stimulation 15 Standing • Takes advantage of gravity during and between contractions • Makes contractions feel less painful and be more productive • Helps fetus line up with angle of maternal pelvis 16 • Helps increase urge to push in second stage of labor Walking • Has the same advantages as standing • Causes changes in the pelvic joints, helping the fetus move through the birth canal Standing and leaning forward on partner, bed, or birthing ball • Has the same advantages as standing • Is a good position for a backrub • May feel more restful than standing • Can be used with electronic fetal monitor Slow dancing (standing with woman’s arms around partner’s neck, head resting on his chest or shoulder, with his hands rubbing woman’s lower back; sway to music and breathe in rhythm if it helps) • Has the same advantages as walking • Back pressure helps relieve back pain • Rhythm and music help woman relax and provide comfort The lunge (standing facing a straight chair with one foot on the seat with knee and foot to the side; bending raised knee and hip, and lunging sideways repeatedly during a contraction, holding each lunge for 5 seconds; partner holds chair and helps with balance) • Widens one side of the pelvis (the side toward lunge) • Encourages rotation of the baby • Can also be done in a kneeling position Sitting upright • Helps promote rest • Has more gravity advantage than lying down • Can be used with electronic fetal monitor Semi-sitting (setting the head of the bed at a 45-degree angle with pillows used for support) • Has the same advantages as sitting upright • Is an easy position if on a bed Sitting on toilet or commode • Has the same advantages as sitting upright • May help relax the perineum for effective bearing down Rocking in a chair • Has the same advantages as sitting upright • May help speed labor (rocking movement) Sitting, leaning forward with support • Has the same advantages as sitting upright • Is a good position for a backrub On all fours, on hands and knees 17 • Helps relieve backache 20 • May be given IV, intrathecally, or epidurally with maximal fetal uptake 2–3 hr after administration • Can cause CNS depression • Decreases fetal variability 21 Butorphanol (Stadol) 1–2 mg IV • Is given IV Q 2–4 hr • Is rapidly transferred across the placenta • Causes neonatal respiratory depression Nalbuphine (Nubain) 10–20 mg IV • Is given IV • Causes less maternal nausea and vomiting • Causes decreased FHR variability, fetal bradycardia, and respiratory depression Fentanyl (Sublimaze) 50–100 mcg IV • Is given IV or epidurally • Can cause maternal hypotension, maternal and fetal respiratory depression • Rapidly crosses placenta Antiemetics Hydroxyzine (Vistaril) 50–100 mg IM • Does not relieve pain but reduces anxiety and potentiates opioid analgesic effects; cannot be given IV • Is used to decrease nausea and vomiting Promethazine (Phenergan) 25–50 mg IV or IM • Is used for antiemetic effect when combined with opioids • Causes sedation and reduces apprehension • May contribute to maternal hypotension and neonatal depression Prochlorperazine (Compazine) 5–10 mg IV or IM • Frequently given with morphine sulfate for sleep during prolonged latent phase; counteracts the nausea that opioids can produce Benzodiazepines Diazepam (Valium) 2–5 mg IV • Is given to enhance pain relief of opioid and cause sedation • May be used to stop eclamptic seizures • Decreases nausea and vomiting • Can cause newborn depression; therefore, lowest possible dose should be used Midazolam (Versed) 1–5 mg IV • Is not used for analgesic but amnesia effect • Is used as adjunct for anesthesia • Is excreted in breast milk OPIOIDS Opioids are morphine-like medications that are most effective for the relief of moderate to severe pain. Opioids typically are administered IV. All opioids are lipophilic and cross the placental barrier but do not affect labor progress in the active phase. Opioids are associated with newborn respiratory depression, 22 decreased alertness, inhibited sucking, and a delay in effective feeding. MATERNAL ASSESSMENT DURING LABOR AND BIRTH Nurs 11 mgt in labor and birth notes • VS • Review prenatal record for r/f of decrease in uteroplacental circulation • Pelvic exam (if no blood is present) or us to assess dilation • Evaluate pain & effectiveness of pain mgmt. during regular intervals Vaginal Examination Purpose is to assess dilation, effacement, membrane status, fetal presentation, position, station & degree of head flexion & presence of fetal skull swelling or molding. Cervical Dilation and Effacement The width of the cervical opening determines dilation, and the length of the cervix assesses effacement. Effacement and dilation are used to assess cervical changes as follows: Effacement: • 0%: cervical canal is 2 cm long • 50%: cervical canal is 1 cm long • 100%: cervical canal is obliterated Dilation: • 0 cm: external cervical os is closed • 5 cm: external cervical os is halfway dilated • 10 cm: external os is fully dilated and ready for birth passage Rupture of Membranes When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged ruptured membranes increase the risk of infection as a result of ascending vaginal pathologic organisms for both mother and fetus. Signs of intrauterine infection to be alert for include maternal fever, fetal and maternal tachycardia, foul odor of vaginal discharge, and an increase in white blood cell count. The fetal membranes usually rupture during the first stage of labor. To confirm if they have ruptured, a sample of fluid is taken from the vagina via a nitrazine yellow dye swab to determine the fluid’s pH. Vaginal fluid is acidic, while amniotic fluid is alkaline and turns a nitrazine swab blue. Sometimes, however, false-positive results can occur, especially in women experiencing a large amount of bloody show because blood is alkaline. The membranes are most likely intact if the nitrazine swab remains yellow to olive green with pH between 5 and 6. The membranes are probably ruptured if the nitrazine swab turns a blue-green to deep blue with pH ranging from 6.5 to 7.5 Assessing Uterine Contractions The contraction resembles a wave, moving downward to the cervix and upward to the fundus of the uterus. Each contraction starts with a building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement) Assessment of the contractions includes frequency, duration, intensity, and uterine resting tone (see Chapter 13 for a more detailed discussion). Uterine contractions with an intensity of 30 mm Hg or greater initiate cervical dilation. During active labor, the intensity usually reaches 50 to 80 mm Hg. Resting tone is normally between 5 and 10 mm Hg in early labor and between 12 and 18 mm Hg in active labor. 2 To palpate the fundus for contraction intensity, place the pads of your fingers on the fundus and describe how it feels: like the tip of the nose (mild), like the chin (moderate), or like the forehead (strong). Palpation of intensity is a subjective judgment of the indentability of the uterine wall; a descriptive term is assigned (mild, moderate, or strong) Performing Leopold Maneuvers Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the nurse’s hands with the fingers together palpate the uterus. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question: • Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? • Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) • Maneuver 3: What is the presenting part? • Maneuver 4: Is the fetal head flexed and engaged in the pelvis? Purpose: To Determine Fetal Presentation, Position, and Lie Place the woman in the supine position and stand beside her. 1. Perform the first maneuver to determine presentation. • Facing the woman’s head, place both hands on the abdomen to determine fetal position in the uterine fundus. • Feel for the buttocks, which will feel soft and irregular (indicates vertex presentation); feel for the head, which will feel hard, smooth, and round (indicates a breech presentation). 2. Complete the second maneuver to determine position. • While still facing the woman, move hands down the lateral sides of the abdomen to palpate on which side the back is located (feels hard and smooth). • Continue to palpate to determine on which side the limbs are located (irregular nodules with kicking and movement). 3. Perform the third maneuver to confirm presentation. • Move hands down the sides of the abdomen to grasp the lower uterine segment and palpate the area just above the symphysis pubis. • Place thumb and fingers of one hand apart and grasp the presenting part by bringing fingers together. • Feel for the presenting part. If the presenting part is the head, it will be round, firm, and ballottable; if it is the buttocks, it will feel soft and irregular. 4. Perform the fourth maneuver to determine attitude. • Turn to face the client’s feet and use the tips of the first three fingers of each hand to palpate the abdomen. • Move fingers toward each other while applying downward pressure in the direction of the symphysis pubis. If you palpate a hard area on the side opposite the fetal back, the fetus is in flexion, because you have palpated the chin. If the hard area is on the same side as the back, the fetus is in extension, because the area palpated is the occiput. 5 In external or indirect monitoring, two ultrasound transducers, each of which is attached to a belt, are applied around the woman’s abdomen. They are similar to the handheld Doppler device. One transducer is called a tocotransducer, a pressure-sensitive device that is applied against the uterine fundus. It detects changes in uterine pressure and converts 6 the pressure registered into an electronic signal that is recorded on graph paper. The tocotransducer is placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions. The other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations. It is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. CONTINUOUS INTERNAL MONITORING Continuous internal monitoring is usually indicated for women or fetuses considered to be at high risk. Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, or medical conditions such as diabetes or hypertension. It involves the placement of a spiral electrode into the fetal presenting part, usually the parietal bone on the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions (Fig. 14.6). The fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus. Specially trained labor and birth nurses are permitted to place the spiral electrode on the fetal head when the membranes rupture to assess the FHR in some health care facilities, but they do not place the intrauterine pressure catheter in the uterus. Internal monitoring does not have to include both an intrauterine pressure catheter and a scalp electrode. A fetal scalp electrode can be used to monitor the fetal heartbeat without monitoring the maternal intrauterine pressure. Both the FHR and the duration and interval of uterine contractions are recorded on the graph paper. This method permits evaluation of baseline heart rate and changes in rate and pattern. Four specific criteria must be met for this type of monitoring to be used: • Ruptured membranes • Cervical dilation of at least 2 cm • Presenting fetal part low enough to allow placement of the scalp electrode • Skilled practitioner available to insert spiral electrode Compared with external monitoring, continuous internal monitoring can accurately detect both short-term (moment-to- moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias. In addition, maternal position changes and movement do not interfere with the quality of the tracing. BASELINE FHR Baseline fetal heart rate refers to the average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes. The normal baseline FHR ranges between 110 and 160 beats per minute (bpm). The normal baseline FHR can be obtained by auscultation, ultrasound, or Doppler, or by a continuous internal direct fetal electrode. Category I: normal Predictive of normal fetal acid–base status and do not require intervention • Baseline rate (110–160 bpm) • Baseline variability moderate • Present or absent accelerations • Present or absent early decelerations • No late or variable decelerations • Can be monitored with intermittent auscultation during labor Category II: indeterminate 7 Not predictive of abnormal fetal acid–base status, but require evaluation and continued surveillance 10 FHR variability is an important clinical indicator that is predictive of fetal acid–base balance and cerebral tissue perfusion. It is influenced by fetal oxygenation status, cardiac output, and drug effects. As the CNS is desensitized by hypoxia and acidosis, FHR decreases until a smooth baseline pattern appears. Loss of variability may be associated with a poor outcome. PERIODIC BASELINE CHANGES Periodic baseline changes are temporary, recurrent changes made in response to a stimulus such as a contraction. The FHR can demonstrate patterns of acceleration or deceleration in response to most stimuli. Fetal accelerations are transitory abrupt increases in the FHR above the baseline that last less than 30 seconds from onset to peak. They are associated with sympathetic nervous stimulation. They are visually apparent, with elevations of FHR of more than 15 bpm above the baseline, and their duration is longer than 15 seconds but less than 2 minutes. They are generally considered reassuring and require no interventions. Accelerations denote fetal movement and fetal well-being and are the basis for nonstress testing. Responding to Fetal Heart Rate Distress during Labor During possible fetal distress that involves lack of variability, late decelerations, and fetal tachycardia, simply changing the woman’s position is inadequate. The nurse should notify the health care provider immediately regarding the situation. Early decelerations are visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They rarely decrease more than 30 to 40 bpm below the baseline. Typically, the onset, nadir, and recovery of the deceleration occur at the same time as the onset, peak, and recovery of the contraction. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Early decelerations are not indicative of fetal distress and do not require intervention. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. They have a gradual waveform and can be recurrent, occurring with each contraction over a period of time. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists. Conditions that may decrease uteroplacental perfusion with resultant decelerations include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia. Recurrent or intermittent late decelerations are always category II (indeterminate) or category III (abnormal) regardless of depth of deceleration. Acute episodes with moderate variability are more likely to be correctable, while chronic episodes with loss of variability are less likely to be correctable. Box 14.1 highlights interventions for category III decelerations.. Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be of a U, V, or W, or they may not resemble other patterns. Variable decelerations usually occur abruptly with quick deceleration. They are the most common deceleration pattern found in the laboring woman and are usually transient and correctable. Variable decelerations are associated with cord compression. However, they are classified either as category II or III depending on the accompanying change in baseline variability. The pattern of variable 11 deceleration consistently related to the contractions with a slow return to FHR baseline warrants further monitoring and evaluation. Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes. The rate usually drops to less than 90 bpm. Many factors are associated with this pattern, including prolonged cord compression, abruptio placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, 12 maternal seizures, regional anesthesia, or uterine rupture. Prolonged decelerations can be remedied by identifying the underlying cause and correcting it. Interventions for Category III Patterns • Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. • Discontinue oxytocin or other uterotonic agent as dictated by the facility’s protocol if it is being administered. • Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression. • Administer oxygen via nonrebreather face mask to increase fetal oxygenation. • Increase the IV fluid rate to improve intravascular volume and correct maternal hypotension. • Assess the client for any underlying contributing causes. • Provide reassurance that interventions are to effect pattern change. • Modify pushing in the second stage of labor to improve fetal oxygenation. • Document any and all interventions and any changes in FHR patterns. • Prepare for an expeditious surgical birth if the pattern is not corrected in 30 minutes. A sinusoidal pattern is described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for more than 20 minutes. A true sinusoidal FHR pattern is rare. It is attributed to a derangement of CNS control of FHR and occurs when a severe degree of hypoxia secondary to fetal anemia and hypovolemia is present. It is always considered a category III pattern, and to correct it, a fetal intrauterine transfusion would be needed. It indicates the fetus is in marked jeopardy. Combinations of FHR patterns obtained by EFM during labor are not infrequent. Category II and III patterns are more significant if they are mixed, persist for long periods, or have frequent prolonged late decelerations, absent or minimal variability, bradycardia or tachycardia, and prolonged variable decelerations lower than 60 bpm. The likelihood of fetal compromise is increased if category II and III patterns are associated with decreased baseline variability or abnormal contraction patterns. Other Fetal Assessment Methods In situations suggesting the possibility of fetal compromise, such as category II or III FHR patterns, further ancillary testing such as umbilical cord blood analysis and fetal scalp stimulation may be used to validate the FHR findings and assist in planning interventions. Umbilical Cord Blood Analysis Neonatal and childhood mortality and morbidity, including cerebral palsy, are often attributed to fetal acidosis as indicated by a low cord pH at birth. Umbilical cord blood acid–base analysis drawn at birth provides an objective method of evaluating a newborn’s condition, identifying the presence of intrapartum hypoxia and acidemia. This test is considered a good indicator of fetal oxygenation and acid–base condition at birth. The normal mean pH value range is 7.2 to 7.3. The pH values are useful for planning interventions for the newborn born with low 5-minute Apgar scores, severe fetal growth restriction (FGR), category II and III patterns during labor, umbilical cord prolapse, uterine rupture, maternal fever, placental abruption, meconium-stained amniotic fluid, and post-term births. The interventions needed for the compromised newborn might include providing an optimal extrauterine environment, fluids, oxygen, medications, and other treatments. Fetal Scalp Stimulation 15 Standing • Takes advantage of gravity during and between contractions • Makes contractions feel less painful and be more productive • Helps fetus line up with angle of maternal pelvis 16 • Helps increase urge to push in second stage of labor Walking • Has the same advantages as standing • Causes changes in the pelvic joints, helping the fetus move through the birth canal Standing and leaning forward on partner, bed, or birthing ball • Has the same advantages as standing • Is a good position for a backrub • May feel more restful than standing • Can be used with electronic fetal monitor Slow dancing (standing with woman’s arms around partner’s neck, head resting on his chest or shoulder, with his hands rubbing woman’s lower back; sway to music and breathe in rhythm if it helps) • Has the same advantages as walking • Back pressure helps relieve back pain • Rhythm and music help woman relax and provide comfort The lunge (standing facing a straight chair with one foot on the seat with knee and foot to the side; bending raised knee and hip, and lunging sideways repeatedly during a contraction, holding each lunge for 5 seconds; partner holds chair and helps with balance) • Widens one side of the pelvis (the side toward lunge) • Encourages rotation of the baby • Can also be done in a kneeling position Sitting upright • Helps promote rest • Has more gravity advantage than lying down • Can be used with electronic fetal monitor Semi-sitting (setting the head of the bed at a 45-degree angle with pillows used for support) • Has the same advantages as sitting upright • Is an easy position if on a bed Sitting on toilet or commode • Has the same advantages as sitting upright • May help relax the perineum for effective bearing down Rocking in a chair • Has the same advantages as sitting upright • May help speed labor (rocking movement) Sitting, leaning forward with support • Has the same advantages as sitting upright • Is a good position for a backrub On all fours, on hands and knees 17 • Helps relieve backache 20 • May be given IV, intrathecally, or epidurally with maximal fetal uptake 2–3 hr after administration • Can cause CNS depression • Decreases fetal variability 21 Butorphanol (Stadol) 1–2 mg IV • Is given IV Q 2–4 hr • Is rapidly transferred across the placenta • Causes neonatal respiratory depression Nalbuphine (Nubain) 10–20 mg IV • Is given IV • Causes less maternal nausea and vomiting • Causes decreased FHR variability, fetal bradycardia, and respiratory depression Fentanyl (Sublimaze) 50–100 mcg IV • Is given IV or epidurally • Can cause maternal hypotension, maternal and fetal respiratory depression • Rapidly crosses placenta Antiemetics Hydroxyzine (Vistaril) 50–100 mg IM • Does not relieve pain but reduces anxiety and potentiates opioid analgesic effects; cannot be given IV • Is used to decrease nausea and vomiting Promethazine (Phenergan) 25–50 mg IV or IM • Is used for antiemetic effect when combined with opioids • Causes sedation and reduces apprehension • May contribute to maternal hypotension and neonatal depression Prochlorperazine (Compazine) 5–10 mg IV or IM • Frequently given with morphine sulfate for sleep during prolonged latent phase; counteracts the nausea that opioids can produce Benzodiazepines Diazepam (Valium) 2–5 mg IV • Is given to enhance pain relief of opioid and cause sedation • May be used to stop eclamptic seizures • Decreases nausea and vomiting • Can cause newborn depression; therefore, lowest possible dose should be used Midazolam (Versed) 1–5 mg IV • Is not used for analgesic but amnesia effect • Is used as adjunct for anesthesia • Is excreted in breast milk OPIOIDS Opioids are morphine-like medications that are most effective for the relief of moderate to severe pain. Opioids typically are administered IV. All opioids are lipophilic and cross the placental barrier but do not affect labor progress in the active phase. Opioids are associated with newborn respiratory depression, 22 decreased alertness, inhibited sucking, and a delay in effective feeding. 25 The routes for regional pain relief include epidural block, combined spinal–epidural, local infiltration, pudendal block, and intrathecal (spinal) analgesia/anesthesia. Local and pudendal routes are used during birth for episiotomies (surgical incisions into the perineum to facilitate birth); epidural and intrathecal routes are used for pain relief during active labor and birth. The major advantage of regional pain management techniques is that the woman can participate in the birthing process and still have good pain control. EPIDURAL ANALGESIA Women requesting epidural analgesia in labor will do so when they feel they need pain relief, and for some, it might be quite early in their labor. Epidural analgesia for labor and birth involves the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space. A small catheter is then passed through the epidural needle to provide continuous access to the epidural space for maintenance of analgesia throughout labor and birt. Epidural analgesia does increase the duration of the second stage of labor and may increase the rate of instrument-assisted vaginal deliveries as well as that of oxytocin administration. Approximately 70% of laboring women in the United States receive an epidural for pain relief during labor. In urban areas, many hospitals approach 90% use of epidurals. An epidural involves the injection of a drug into the epidural space, which is located outside the dura mater between the dura and the spinal canal. The epidural space is typically entered through the third and fourth lumbar vertebrae with a needle, and a catheter is threaded into the epidural space. An epidural can be used for both vaginal and cesarean births. It has evolved from a regional block producing total loss of sensation to analgesia with minimal blockade. The effectiveness of epidural analgesia depends on the technique and medications used. Theoretically, epidural local anesthetics could block all labor pain if used in large volumes and high concentrations. However, pain relief is balanced against other goals such as walking during the first stage of labor, pushing effectively in the second stage, and minimizing maternal and fetal side effects. An epidural is contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects, cardiac disease, obesity, infections, and hypovolemia. It is also contraindicated for the woman who is receiving anticoagulation therapy. Complications include nausea and vomiting, hypotension, fever, pruritus, intravascular injection, maternal fever, allergic reaction, and respiratory depression. Effects on the fetus during labor include fetal distress secondary to maternal hypotension. Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help minimize hypotension. The addition of opioids, such as fentanyl or morphine, to the local anesthetic helps decrease the amount of motor block obtained. Continuous infusion pumps can be used to administer the epidural analgesia, allowing the woman to be in control and administer a bolus dose on demand. COMBINED SPINAL–EPIDURAL ANALGESIA Another epidural technique is combined spinal–epidural (CSE) analgesia. This technique involves inserting the epidural needle into the epidural space and subsequently inserting a small-gauge spinal needle through the epidural needle into the subarachnoid space. An opioid without a local anesthetic is injected into this space. The spinal needle is then removed and an epidural catheter is inserted for later use. CSE is advantageous because of its rapid onset of pain relief (within 3 to 5 minutes) that can last up to 3 hours. It also allows the woman’s motor function to remain active. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact. The CSE technique provides greater flexibility and reliability for labor than either spinal or epidural analgesia alone. When compared with traditional epidural or spinal analgesia, which often keeps the 26 woman lying in bed, CSE allows her to ambulate (“walking epidural”). A recent study contrasting the CSE analgesia approach with traditional and low-dose epidural analgesia in labor identified that CSE analgesia was associated with a greater incidence of pruritus but a lower incidence of urinary retention and need for rescue analgesia than epidural alone. In addition, CSE analgesia had a faster onset of pain relief, and there were no 27 differences in labor outcomes. Ambulating during labor provides several benefits; it may help control pain better, shorten the first stage of labor, increase the intensity of the contractions, and decrease the possibility of an operative vaginal or cesarean birth. Although women can walk with CSE, they often choose not to because of sedation and fatigue. Often health care providers do not encourage or assist women with ambulating for fear of injury. Nurses need to evaluate for ambulation safety that includes no postural hypotension and normal leg strength by demonstrating a partial knee bend while standing; they also need to assist with ambulation at all times. Currently, anesthesiologists are performing walking epidurals using continuous infusion techniques as well as CSE and client-controlled epidural analgesia. Complications include maternal hypotension, intravascular injection, accidental intrathecal blockade, postdural puncture headache, pruritus, inadequate or failed block, maternal fever, and pruritus. Hypotension and associated FHR changes are managed with maternal positioning (semi-Fowler position), IV hydration, and supplemental oxygen. PUDENDAL NERVE BLOCK The pudendal nerve block provides long-lasting perineal analgesia. A pudendal nerve block refers to the injection of a local anesthetic agent (e.g., bupivacaine, ropivacaine) into the pudendal nerves near each ischial spine. It provides pain relief in the lower vagina, vulva, and perineum. A pudendal block is used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor. It must be administered about 15 minutes before it would be needed to ensure its full effect. A transvaginal approach is generally used to inject an anesthetic agent at or near the pudendal nerve branch. Neither maternal nor fetal complications are common. SPINAL (INTRATHECAL) ANALGESIA/ANESTHESIA The spinal (intrathecal) pain management technique involves injection of an anesthetic “caine” agent with or without opioids into the subarachnoid space to provide pain relief during labor or cesarean birth. The subarachnoid space is a fluid-filled area located between the dura mater and the spinal cord. Spinal anesthesia is frequently used for elective and emergent cesarean births. The contraindications are similar to those for an epidural block. Adverse reactions for the woman include hypotension and spinal headache. The subarachnoid injection of opioids alone or in combination, a technique termed “intrathecal narcotics,” has been used for laboring women successfully for decades. A narcotic is injected into the subarachnoid space, providing rapid pain relief while still maintaining motor function and sensation. An intrathecal narcotic is given during the active phase (more than 5 cm of dilation) of labor. Compared with epidural blocks, intrathecal narcotics are easy to administer, require a smaller volume of medication, produce excellent muscular relaxation, provide rapid-onset pain relief, are less likely to cause newborn respiratory depression, and do not cause motor blockade. Although pain relief is rapid with this technique, it is limited by the narcotic’s duration of action, which may be only a few hours and not last through the labor. Adding dexmedetomidine to the morphine or fentanyl prolonged the analgesia considerably during many labors in a recent study. General Anesthesia Obstetric guidelines recommend neuraxial anesthesia for cesarean births in most women. General anesthesia is typically reserved for emergency cesarean births when there is not enough time to provide spinal or epidural anesthesia or if the woman has a contraindication to the use of regional anesthesia. It can be started quickly and causes a rapid loss of consciousness. General anesthesia can be administered by IV injection, inhalation of anesthetic agents, or both. Commonly, thiopental, a short-acting barbiturate, or propofol is given IV to produce unconsciousness. This is followed by administration of a muscle relaxant. After the woman is intubated, nitrous oxide and oxygen are administered. A volatile halogenated agent may also be administered to produce amnesia. All 30 • All flow sheets and forms to validate care given • All education given to the client and the response to it 31 • Facts, not personal opinions • Detailed descriptions of any adverse outcome • Initial nursing assessment, all encounters, and discharge plan • All telephone conversations This standard of documentation is needed to prevent or defend against litigation, which is prevalent in the childbirth arena. Assessing the Woman upon Admission The nurse usually first comes in contact with the woman either by phone or in person. The nurse should ascertain whether the woman is in true or false labor and whether she should be admitted or sent home. Upon admission to the labor and birth suite, the highest priorities include assessing FHR, assessing cervical dilation and effacement, and determining whether membranes have ruptured or are intact. These assessment data will guide the critical thinking in planning care for the client. If the initial contact is by phone, establish a therapeutic relationship with the woman. Speaking in a calm caring tone facilitates this. Nurses providing a telephone triage service need to have sufficient clinical experience and have clear lines of responsibility to enable sound decision-making. When completing a phone assessment, include questions about: • Estimated date of birth to determine if term or preterm • Fetal movement (frequency in the past few days) • Other premonitory signs of labor experienced • Parity, gravida, and previous childbirth experiences • Time from start of labor to birth in previous labors • Characteristics of contractions, including frequency, duration, and intensity • Appearance of any vaginal bloody show • Membrane status (ruptured or intact) • Presence of supportive adult in household or if she is alone When speaking with the woman over the telephone, review the signs and symptoms that denote true versus false labor, and suggest various positions she can assume to provide comfort and increase placental perfusion. Also suggest walking, massage, and taking a warm shower to promote relaxation. Outline what foods and fluids are appropriate for oral intake in early labor. Throughout the phone call, listen to the woman’s concerns and answer any questions clearly. Reducing the risk of liability exposure and avoiding preventable injuries to mothers and fetuses during labor and birth can be accomplished by adhering to two basic tenets of clinical practice: (1) use applicable evidence and/or published standards and guidelines as the foundation of care, and (2) whenever a clinical choice is presented, choose client safety. With these two tenets in mind, advise the woman on the phone to contact her health care provider for further instructions or to come to the facility to be evaluated, since ruling out true labor and possible maternal–fetal complications cannot be done accurately over the phone. Additional nursing responsibilities associated with a phone assessment include: • Consulting the woman’s prenatal record for parity status, estimated date of birth, and untoward events • Calling the health care provider to inform them of the woman’s status • Preparing for admission to the perinatal unit to ensure adequate staff assignment • Notifying the admissions office of a pending admission If the nurse’s first encounter with the woman is in person, an assessment is completed to determine whether she should be admitted to the perinatal unit or sent home until her labor advances. Recent research findings suggest that women admitted before active labor are approximately twice as likely to 32 be augmented with oxytocin and give birth via cesarean when compared with women admitted in active labor. Nurses need to make careful assessment of labor progression prior to labor admission to decrease early admissions and to improve labor safety and birth outcomes. Entering a facility is often an intimidating and stressful event for women since it is an unfamiliar environment. Giving birth for the first time is a pivotal event in the lives of most women. Therefore, demonstrate respect when addressing the client; listen carefully and express interest and concern. Nurses must value and respect women and promote their self-worth and 35 • Ability to ambulate safely These assessment parameters form a baseline against which the nurse can compare all future values throughout labor. The findings should be similar to those of the woman’s prepregnancy and pregnancy findings with the exception of her pulse rate, which might be elevated secondary to her anxious state with beginning labor. LABORATORY STUDIES Upon admission, laboratory studies are typically done to establish a baseline. Although the exact tests may vary among facilities, they usually include a urinalysis via clean-catch urine specimen and complete blood count. Blood typing and Rh factor analysis may be necessary if the results of these are unknown or unavailable. In addition, if the following test results are not included in the maternal prenatal history, it may be necessary to perform them at this time. They include syphilis screening, hepatitis B (HbsAg) screening, group B streptococcus, human immune deficiency virus (HIV) testing (if the woman gives consent), and possible drug screening if the history is positive. Group B streptococcus (GBS) is a Gram-positive organism that colonizes in the female genital tract and rectum and is present in 10% to 30% of all healthy women. These women are asymptomatic carriers but can cause GBS disease of the newborn through vertical transmission during labor and horizontal transmission after birth. The mortality rate of infected newborns varies according to time of onset (early or late). Risk factors for GBS include maternal intrapartum fever, prolonged ruptured membranes (longer than 12 to 18 hours), previous birth of an infected newborn, and GBS bacteriuria in the present pregnancy. The Centers for Disease Control and Prevention, ACOG, and the American Academy of Pediatrics have guidelines that advise universal screening of pregnant women at 35 to 37 weeks’ gestation for GBS and intrapartum antibiotic therapy for GBS carriers. These guidelines reaffirm the major prevention strategy— universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture-positive and high- risk women. Also included are new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn infants. Maternal infections associated with GBS include acute chorioamnionitis, endometritis, and urinary tract infection. Neonatal clinical manifestations include pneumonia and sepsis. Identified GBS carriers receive IV antibiotic prophylaxis (penicillin G or ampicillin) at the onset of labor or ruptured membranes. The ACOG, CDC, AWHONN, and the U.S. Preventive Services Task Force recommend that all pregnant women be offered a screening test for HIV antibodies on their first prenatal visit, again during the third trimester if engaging in high- risk behaviors, and upon admission to the labor and birth area. The CDC estimates that approximately 50,000 individuals contract HIV in the United States each year, and 250,000 individuals have undiagnosed HIV infections. If her HIV status is not documented, the woman being admitted to the labor and birth suite should have rapid HIV testing done. To reduce perinatal transmission, women who are HIV-positive are given a combination of antiretroviral drugs. To further reduce the risk of perinatal transmission, ACOG and the U.S. Public Health Service recommend that women who are infected with HIV and have plasma viral loads of more than 1,000 copies/mL be counseled regarding the benefits of elective cesarean birth. In the absence of any medical intervention, the rate of vertical transmission of HIV to the fetus can range from 15% to 45%. However, with the use of antiretroviral regimens, the transmission rate is reduced to less than 2%. Additional interventions to reduce the transmission risk would include avoiding use of a scalp electrode for fetal monitoring or doing a scalp blood sampling for fetal pH, delaying amniotomy, encouraging formula 36 feeding after birth, and avoiding invasive procedures such as forceps- or vacuum-assisted devices. The nurse stresses the importance of all interventions and the goal to reduce transmission of HIV to the newborn. Continuous Assessment during the First Stage of Labor After the admission assessment is complete and the woman and her support person have been oriented to the room, equipment, and procedures, assessment continues for changes that would indicate that labor is progressing as expected. 37 Assess the woman’s knowledge, experience, and expectations of labor. Typically, blood pressure, pulse, and respirations are assessed every hour during the latent phase of labor unless the clinical situation dictates that vital signs be taken more frequently. During the active phase of labor, vital signs are assessed every 30 minutes. Temperature is taken every 4 hours throughout the first stage of labor and every 2 hours after membranes have ruptured to detect an elevation indicating an ascending infection. Vaginal examinations are performed periodically to track labor progress. This assessment information is shared with the woman to reinforce that she is making progress toward the goal of birth. Uterine contractions are monitored for frequency, duration, and intensity every 30 to 60 minutes during the latent phase, and every 15 to 30 minutes during the active phase. Note the changes in the character of the contractions as labor progresses, and inform the woman of her progress. Continually determine the woman’s level of pain and her ability to cope and use relaxation techniques effectively. When the fetal membranes rupture, spontaneously or artificially, assess the FHR and check the amniotic fluid for color, odor, and amount. Assess the FHR intermittently or continuously via electronic monitoring. During the latent phase of labor, assess the FHR every 30 to 60 minutes; in the active phase, assess the FHR at least every 15 to 30 minutes. Also, be sure to assess the FHR before ambulation, before any procedure, and before administering analgesia or anesthesia to the mother. Table 14.3 summarizes assessments for the first stage of labor. Vital signs (BP, pulse, respirations) • Latent: Every 30–60 min • Active: Every 15–30 minutes Temperature • Latent: Every 4 hours; more frequently if membranes are ruptured • Active: Every 4 hours; more frequently if membranes are ruptured Contractions (frequency, duration, intensity) • Latent: Every 30–60 minutes by palpation or continuously if EFM • Active: Every 15–30 minutes by palpation or continuously if EFM Fetal heart rate • Latent: Every hour by Doppler or continuously by EFM • Active: Every 15–30 minutes by Doppler or continuously by EFM Vaginal examination • Latent: Initially on admission to determine phase and as needed based on maternal cues to document labor progression • Active: As needed to monitor labor progression Behavior/psychosocial • Latent: With every client encounter: talkative, excited, anxious • Active: With every client encounter: self-absorbed in labor; intense and quiet now Nursing Interventions Nursing interventions during the admission process should include: • Asking about the client’s expectations of the birthing process • Providing information about labor, birth, pain management options, and relaxation techniques 40 and promotes support from and active participation of your partner) NURSING MANAGEMENT DURING THE SECOND STAGE OF LABOR 41 • Side-lying with pillows between the knees for comfort (offers a restful position and improves oxygen flow to the uterus) • Semi-sitting in bed or on a couch leaning against the partner (reduces back pain because fetus falls forward, away from the sacrum) • Sitting in a chair with one foot on the floor and one on the chair (changes pelvic shape) • Leaning forward by straddling a chair, a table, or a bed or kneeling over a birth ball (reduces back pain, adds the force of gravity to promote descent; possible pain relief if partner can apply sacral pressure) • Encourage any position of comfort the woman chooses to labor in and give birth. • Sitting in a rocking chair or on a birth ball and shifting weight back and forth (provides comfort because rocking motion is soothing; uses the force of gravity to help fetal descent) • Lunge by rocking weight back and forth with foot up on chair during contraction (uses force of gravity by being upright; enhances rotation of fetus through rocking) • Women should be allowed to position themselves in whatever position they find most comfortable. • Open knee–chest position (helps relieve back discomfort) Management of the second stage of labor often follows tradition-based routines rather than evidence- based practices. Current evidence for management of the second stage of labor supports the practices of delayed pushing, spontaneous (nondirected) pushing, and maternal choice positions. To be able to help women through the second stage of labor requires the nurse to have a comprehensive understanding of physiology and be aware of the latest evidence-based research and apply it to practice. Nursing care during the second stage of labor focuses on supporting the woman and her partner in making active decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing instruction and assistance, and using maternal positions that can enhance descent and reduce pain. Women in the past gave birth unaided by following their bodies’ signals to birth their babies, so the role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her instinct of when and how to push. In the absence of any complications, nurses should not be controlling this stage of labor but rather empowering women to achieve a satisfying experience. The primary rationale for directing women to push is to shorten the second stage of labor. Common practice in many labor units is still to coach women to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that is not supported by research. Research suggests that directed pushing during the second stage may be accompanied by a significant decline in fetal pH and may cause maternal muscle and nerve damage if done too early. Shortening the phase of active pushing and lengthening the early phase of passive descent can be achieved by encouraging the woman not to push until she has a strong desire to do so and until the descent and rotation of the fetal head are well advanced. Effective pushing can be achieved by assisting the woman with assuming a more upright or squatting position. Supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice. Perineal lacerations or tears can occur during the second stage when the fetal head emerges through the vaginal introitus. The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a second- degree laceration extends through the muscles of the perineal body; a third- degree laceration continues through the anal sphincter muscle; and a fourth-degree laceration also involves the anterior rectal wall. Special attention needs to be paid to third- and fourth-degree lacerations to prevent fecal incontinence. Risks for third- or fourth-degree lacerations include nulliparity, being of Asian or Pacific Islander descent, increased birth weight of the newborn, operative vaginal birth, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations. The primary care provider should repair any lacerations during the third stage of labor. 42 NURSING ANALYSIS: Anxiety related to labor and birth process and fear of the unknown related to client’s first experience CONTINUOUS ASSESSMENT DURING THE SECOND STAGE OF LABOR 45 Monitor vital signs (every 2 hours after rupture of membranes) and FHR frequently as per protocol to allow for early detection of problems; report fetal tachycardia (early sign of maternal infection) to ensure prompt treatment. Provide frequent perineal care and pad changes to maintain good perineal hygiene. Change linens and woman’s gown as needed to maintain cleanliness. Ensure that vaginal examinations are performed only when needed to prevent introducing pathogens into the vaginal vault. Monitor lab test results such as white blood cell count to assess for elevations indicating infection. Encourage emptying of her bladder at least every 2 hours to not impede fetal descent. Use aseptic technique for all invasive procedures to prevent infection transmission. Carry out good hand washing techniques before and after procedures and use standard precautions as appropriate to minimize risk of infection transmission. Document amniotic fluid characteristics like color and odor to establish baseline for comparison. An episiotomy is an incision made in the perineum to enlarge the vaginal outlet and theoretically to shorten the second stage of labor. Alternative measures such as warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent cutting it. Certified nurse midwives can cut and repair episiotomies, but they frequently use alternative measures if possible. TAKE NOTE! Restrictive use of episiotomy has been recommended by ACOG given the risks of the procedure and unclear benefits of routine use. The midline episiotomy has been the most commonly used one in the United States because it can be easily repaired and causes the least amount of pain. The application of warmed compresses and/or intrapartum perineal massage is associated with a decrease in trauma to the perineal area and reduced need for an episiotomy. Routine episiotomy has declined since liberal usage has been discouraged by ACOG except to avoid several maternal lacerations or to expedite difficult births. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds with a sharp increase in cesarean births, which may indicate that health care providers are favoring cesarean births for difficult births. Assessment is continuous during the second stage of labor. Hospital policies dictate the specific type and timing of assessments, as well as the way in which they are documented. Assessment involves identifying the signs typical of the second stage of labor, including: • Increase in apprehension or irritability • Spontaneous rupture of membranes • Sudden appearance of sweat on upper lip • Increase in blood-tinged show • Low grunting sounds from the woman • Complaints of rectal and perineal pressure • Beginning of involuntary bearing-down efforts Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labor as indicated by FHR monitor strips; amniotic fluid for color, odor, and amount when membranes are ruptured; and the coping status of the woman and her partner. Assessment also focuses on determining the progress of labor. Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn’s head during and between bearing- 46 down efforts, and crowning (fetal head is visible at vaginal opening. A vaginal examination is completed to determine if it is appropriate for the woman to push. Pushing is appropriate if the cervix has fully dilated to 10 cm and the woman feels the urge to do so. Nursing Interventions 47 Nursing interventions during this stage focus on motivating the woman, assisting her with positioning, encouraging her to put all her efforts to pushing this newborn to the outside world, and giving her feedback on her progress. If the woman is pushing without progress, suggest that she keep her eyes open during the contractions and look toward where the newborn is coming out. Changing positions frequently will also help her make progress. Positioning a mirror so the woman can visualize the birthing process and how successful her pushing efforts are can help motivate her. During the second stage of labor, an ideal position would be one that opens the pelvic outlet as wide as possible, provides a smooth pathway for the fetus to descend through the birth canal, takes advantage of gravity to assist the fetus to descend, and gives the mother a sense of being safe and in control of the labor process. Some suggestions for positions in the second stage include: • Lithotomy with feet up in stirrups: most convenient position for caregivers, though evidence does not support this position physiologically • Semi-sitting with pillows underneath knees, arms, and back • Lateral/side-lying with curved back and upper leg supported by partner • Sitting on birthing stool: opens pelvis, enhances the pull of gravity, and helps with pushing • Squatting/supported squatting: gives the woman a sense of control • Using a peanut ball between the legs to widen the pelvic diameter • Kneeling with hands on bed and knees comfortably apart Other important nursing interventions during the second stage include: • Providing continuous comfort measures such as mouth care, encouraging position changes, changing bed linen and underpads, and providing a quiet, focused environment • Instructing the woman on the following bearing-down positions and techniques: • Pushing only when she feels an urge to do so • Delaying pushing for up to 90 minutes after complete dilation • Using abdominal muscles when bearing down • Using short pushes of 6 to 7 seconds • Focusing attention on the perineal area to visualize the newborn • Relaxing and conserving energy between contractions • Pushing several times with each contraction • Pushing with an open glottis and slight exhalation • Continuing to monitor contraction and FHR patterns to identify problems • Providing brief, explicit directions throughout this stage • Continuing to provide psychosocial support by reassuring and coaching • Facilitating the upright position to encourage the fetus to descend • Continuing to assess blood pressure, pulse, respirations, uterine contractions, bearing-down efforts, FHR, and coping status of the client and her partner • Providing pain management if needed • Providing a continuous nursing presence • Offering praise for the client’s efforts • Preparing for and assisting with delivery by: • Notifying the health care provider of the estimated time frame for birth • Preparing the delivery bed and positioning the client • Preparing the perineal area according to the facility’s protocol • Offering a mirror and adjusting it so the woman can watch the birth • Explaining all procedures and equipment to the client and her partner • Setting up delivery instruments needed while maintaining sterility • Using standard precautions during the birthing process to avoid body fluid splashes • Recording the time of birth, time of placenta, and type of birth NURSING MANAGEMENT DURING THE THIRD STAGE OF LABOR 50 During the third stage of labor, strong uterine contractions continue at regular intervals under the continuing influence of oxytocin. The uterine muscle fibers shorten, or retract, with each contraction, leading to a gradual decrease in the size of the uterus, which helps shear the placenta away from its attachment site. The third stage is complete when the placenta is delivered. Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and observing for signs of placental separation, being available to assist with the delivery of the placenta, recording the time of expulsion, and inspecting the placenta for intactness. The nurse should also be assessing the mother by palpating the uterus before and after placental expulsion. Three hormones play important roles in the third stage. During this stage, the woman experiences peak levels of oxytocin and endorphins, while the high adrenaline levels that occurred during the second stage of labor to aid with pushing begin falling. The hormone oxytocin causes uterine contractions and helps the woman enact instinctive mothering behaviors such as holding the newborn close to her body and cuddling the baby. Skin-to-skin contact immediately after birth and the newborn’s first attempt at breast-feeding further augment maternal oxytocin levels, strengthening the uterine contractions that will help the placenta separate and the uterus contract to prevent hemorrhage. Endorphins, the body’s natural opiates, produce an altered state of consciousness and aid in blocking out pain. In addition, the drop in adrenaline level from the second stage, which had kept the mother and baby alert at first contact, causes most women to shiver and feel cold shortly after giving birth. TAKE NOTE! A crucial role for nurses during the third stage of labor is to protect the natural hormonal process by ensuring unhurried and uninterrupted contact between mother and newborn after birth, providing warmed blankets to prevent shivering and allowing skin-to-skin contact with initial breast- feeding. Continuing Assessment during the Third Stage of Labor Assessment during the third stage of labor includes: • Monitoring placental separation by looking for the following signs: • Firmly contracting uterus • Change in uterine shape from discoid to globular ovoid • Sudden gush of dark blood from vaginal opening • Lengthening of umbilical cord protruding from vagina • Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) • Assessing for any perineal trauma, such as the following, before allowing the birth attendant to leave: • Firm fundus with bright red blood trickling: laceration • Boggy fundus with red blood flowing: uterine atony • Boggy fundus with dark blood and clots: retained placenta • Inspecting the perineum for condition of episiotomy if performed • Assessing for perineal lacerations and ensuring repair by birth attendant Nursing Interventions Interventions during the third stage of labor include: 51 • Describing the process of placental separation to the couple • Instructing the woman to push when signs of separation are apparent • Administering an oxytocic agent if ordered and indicated after placental expulsion • Providing support and information about episiotomy and/or laceration if applicable • Cleaning and assisting the client into a comfortable position after birth, making sure to lift both legs out of stirrups (if used) simultaneously to prevent strain NURSING MANAGEMENT DURING THE FOURTH STAGE OF LABOR 52 • Assessing the woman’s knowledge of breast-feeding to determine educational needs • Educating the woman about latching on, positioning, infant sucking and swallowing • Repositioning the birthing bed to serve as a recovery bed if applicable • Assisting with transfer to the recovery area if applicable • Providing warmth by replacing warmed blankets over the woman • Applying an ice pack to the perineal area to provide comfort to episiotomy if indicated • Explaining what assessments will be carried out over the next hour and offering positive reinforcement for actions • Ascertaining any needs • Monitoring maternal physical status by assessing: • Vaginal bleeding: amount, consistency, and color • Vital signs: blood pressure, pulse, and respirations taken every 15 minutes • Uterine fundus, which should be firm, in the midline, and at the level of the umbilicus • Recording all birthing statistics and securing primary caregiver’s signature • Documenting birthing event in the birth book (official record of the facility that outlines every birth event), detailing any deviations The fourth stage of labor begins after the placenta is expelled and lasts up to 4 hours after birth, during which time recovery takes place. This recovery period may take place in the same room where the woman gave birth, in a separate recovery area, or in the postpartum room. During this stage, the woman’s body is beginning to undergo the many physiologic and psychological changes that occur after birth. The focus of nursing management during the fourth stage of labor involves frequent close observation for hemorrhage, provision of comfort measures, and promotion of family attachment. Assessment Assessments during the fourth stage center on the woman’s vital signs, status of the uterine fundus and perineal area, comfort level, lochia amount, and bladder status. During the first hour after birth, vital signs are taken every 15 minutes, then every 30 minutes for the next hour if needed. The woman’s blood pressure should remain stable and within normal range after giving birth. A decrease may indicate uterine hemorrhage; an elevation might suggest preeclampsia. The pulse is usually typically slower (60 to 70 bpm) than during labor. This may be associated with a decrease in blood volume following placental separation. An elevated pulse rate may be an early sign of blood loss. The blood pressure usually returns to its prepregnancy level and therefore is not a reliable early indicator of shock. Fever is indicative of dehydration (less than 100.4°F or 38°C) or infection (above 101°F), which may involve the genitourinary tract. Respiratory rate is usually between 16 and 24 breaths per minute and regular. Respirations should be unlabored unless there is an underlying preexisting respiratory condition. Assess fundal height, position, and firmness every 15 minutes during the first hour following birth. The fundus needs to remain firm to prevent excessive postpartum bleeding. The fundus should be firm (feels like the size and consistency of a grapefruit), located in the midline and below the umbilicus. If it is not firm (boggy), gently massage it until it is firm (see Nursing Procedure 22.1 for more information). Once firmness is obtained, stop massaging. TAKE NOTE! If the fundus is displaced to the right of the midline, suspect a full bladder as the cause. The vagina and perineal areas are quite stretched and edematous following a vaginal birth. Assess the 55 A nurse provides physical and emotional support during the labor and birth process to assist a woman in achieving her goals. When a woman is admitted to the labor and birth area, the admitting nurse must assess and evaluate the risk status of the pregnancy and initiate appropriate interventions to provide optimal care for the client. 56 Completing an admission assessment includes taking a maternal health history; performing a physical assessment on the woman and fetus, including her emotional and psychosocial status; and obtaining the necessary laboratory studies. The nurse’s role in fetal assessment for labor and birth includes determining fetal well-being and interpreting signs and symptoms of possible compromise. Determining the FHR pattern and assessing amniotic fluid characteristics are key. FHR can be assessed intermittently or continuously. Although the intermittent method allows the client to move around during labor, the information obtained intermittently does not provide a complete picture of fetal well-being from moment to moment. Assessment parameters of the FHR are classified as baseline rate, baseline variability, and periodic changes in the rate (accelerations and decelerations). The nurse monitoring the laboring client needs to be knowledgeable about which category the FHR pattern is in so that appropriate interventions can be instituted. For a category III FHR pattern, the nurse should notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. In addition to interpreting assessment findings and initiating appropriate inventions for the laboring client, accurate and timely documentation must be carried out continuously. Nursing management for the woman during labor and birth includes comfort measures, emotional support, information and instruction, advocacy, and support for the partner. Nursing care during the first stage of labor includes taking an admission history (reviewing the prenatal record), checking the results of routine laboratory work and special tests done during pregnancy, asking the woman about her childbirth preparation (birth plan, classes taken, coping skills), and completing a physical assessment of the woman to establish baseline values for future comparison. Nursing care during the second stage of labor focuses on supporting the woman and her partner in making decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing support and assistance, and encouraging the use of maternal positions that can enhance descent and reduce the pain. Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness. The focus of nursing management during the fourth stage of labor involves frequently observing the mother for hemorrhage, providing comfort measures, and promoting family attachment.