lOMoARcPSD|21943190 Labor and Delivery - Lecture notes 1 Nursing Care Management (Colegio San Agustin – Bacolod) Studocu is not sponsored or endorsed by any college or university Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 1 NCM 107: Maternal & Child Nursing INTRAPARTAL Theory of the Aging Placenta Learning Objectives: Progesterone Deprivation Theory 1. Explain thoroughly the theories of labor onset. Prostaglandin Theory Rising fetal cortisol level 2. Discuss the role of the passenger, passage and powers in labor. 3. PRELIMINARY SIGNS OF LABOR Assess the woman’s needs and readiness 4. Formulate simple nursing diagnosis related to the physiological and behavioral aspects of labor and delivery. 1. Lightening – descent of the fetal presenting part into the pelvis – 10-14 days before labor (primipara), on the day of labor (multipara) 5. Establish a nursing care plan to meet the needs of the woman and family throughout labor and delivery. Results in: 6. Plan nursing interventions to promote optimal outcomes for the woman and her family during labor and birth 7. Implement planned nursing interventions 8. Evaluate expected outcomes for achievement and effectiveness of care 7. Implement planned nursing interventions 8. Evaluate expected outcomes achievement and effectiveness of care. for o Relief of dyspnea o Increase frequency of urination o Leg cramps o Increase vaginal discharge o Decrease fundal height PRELIMINARY SIGNS OF LABOR Increase in level of activity LABOR & DELIVERY Braxton Hicks contractions LABOR is the series of events by which uterine contraction and abdominal pressure expel the fetus and placenta from the woman’s body Ripening of the cervix – internal Weight Loss DELIVERY Actual event of birth SIGNS OF TRUE LABOR THEORIES OF LABOR ONSET Uterine contractions – effective, productive and involuntary Uterine Stretch Theory Oxytocin Stimulation Theory 2. Show- cervical mucus with blood tinge Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 2 NCM 107: Maternal & Child Nursing 3. Rupture of the membranes (BOW) False Contractions possible effects : Do not increase in duration, frequency or intensity. Do not achieve cervical dilation Intrauterine infection prolapse of the cord True Contraction Increases in duration frequency & intensity Achieve cervical dilation COMPONENTS OF LABOR 1. PASSAGEWAY a. Pelvis DIFFERENCE BETWEEN FALSE & TRUE LABOR False Pelvis – ilia, support the uterus & directs the fetus to true pelvis False Labor Begin & remain irregular Felt inabdominally & remain confined in the abdomen & groin Often disappear with ambulation & sleep True Pelvis – forms the passageway of the fetus during labor True Labor PELVIC SHAPES Begin irregularly but become regular & predictable Felt initially in the lower back & sweep around to the abdomen in a wave 1. GYNECOID 2. ANTHROPOID- elongated Continue no matter what the woman’s level of activity 3. ANDROID- male pelvis 4. PLATYPELLOID- kind of flat (not ideal pelvis) 1 Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) 2 3 4 lOMoARcPSD|21943190 3 NCM 107: Maternal & Child Nursing Pelvic Measurements A. Cervix before effacement begins a) Diagonal conjugate (anteroposterior diameter of the inlet) 12.5 cm B. Effacement in its early phase C. Effacement with some dilation b) Transverse Diameter of the Outlet 13.5 cm D. Complete effacement and dilation c) R & L Oblique Diameter 12.75 cm 2. Passenger Cervix Fetus Effacement - shortening & thinning of the cervical canal. (%) head of the fetus is the most impt part of the body because: Dilation - increase in cervical diameter. (cm) a. It is the largest part of the fetal body In primis: effacement first, ff by dilatation In multis: dilatation and effacement takes place at the same time. b. It is often the presenting part c. It is the least compressible part Cranial bones o o o o o o Effacement 1 frontal 2 parietal 2 temporal 1 occipital 1 sphenoid 1 ethmoid Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 4 NCM 107: Maternal & Child Nursing Suture lines – allow the skull bones to overlap to reduce size of fetal head. o o o o sagittal suture frontal suture coronal suture lambdoidal suture STATION -relationship of the presenting part of the fetus to the level of the ischial spines -relationship of the presenting part of the fetus to the level of the ischial spines Fetal Descent Stations (Birth Presentation) Fontanels - membrane covered spaces found in between the intersections of suture lines. They help determine the position and presentation of the fetus. o o Anterior fontanel/Bregma Posterior fontanel/Lambda o o o At -4 station, head is “floating” At 0 station – head is “engaged” At +4 station – head is “at outlet” Molding - overlapping of the skull bones Attitude Fetal Lie- relationship of the long axis of the fetus to the long axis of the mother the degree of flexion the fetus assumes a) Complete flexion – fetus is in good attitude b) Moderate flexion – military position c) Partial extension – browis the presenting part d) Poor flexion – back is arched, neck extended. Face presentation Fetal Presentations Vertex Face/brow Shoulder/ transverse Frank breech Complete breech Incomplete/ footling breech Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 5 NCM 107: Maternal & Child Nursing Components of Labor Fetal Position o relationship of the presenting part to the specific quadrant of the woman’s pelvis Four quadrants of the mother’s pelvis 1) 2) 3) 4) right anterior right posterior left anterior left posterior Four parts of the fetus as landmarks 1) 2) 3) 4) vertex presentation- occiput (O) face presentation – chin/mentum (M) breech presentation – sacrum (Sa) shoulder presentation – acromion process (A) 3. Power A. Uterine Contractions 1. Phase Increment/crescendo Acme/apex Decrement/ decrescendo Characteristics of uterine contractions Involuntary Intermittent Involves discomfort (labor pains) o a. Mild – slightly tense fundus and easy to indent with fingertips Position is marked by an abbreviation of 3 letters b. Moderate – firm fundus, difficult to indent with finger middle letter – denotes fetal landmarks- O for occiput, M for mentum, Sa for sacrum and A for acromion process – first letter – whether the landmark is pointing to the mother’s right (R) or left (L) last letter – whether the landmark points anteriorly (A), posteriorly (P) or transverse (T) What is the position if: 1) Vertex presentation at the left side of the mother anteriorly 2) Shoulder presentation located at the right side of the mother posteriorly. Intensity – strength of uterine contraction c. Strong – rigid, boardlike fundus that is almost impossible to indent with finger Frequency – Measured from the beginning of a contraction to the beginning of the next contraction o Duration - Measured from the beginning of a contraction to the end of the same contraction o Interval - Measured from the end of one contraction to the beginning of the next contraction Components of Labor 4. Psyche Maternal attitudes and behaviors during labor depends on the ff. Factors: o Perception and meaning of childbirth o Readiness and preparation for childbirth o Past experiences o Coping skills o Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 6 NCM 107: Maternal & Child Nursing o o Cultural and social background Presence of significant others and support system Length of Normal labor Primis 1st stage 2nd stage 3rd stage Total 14 hrs Prolonged laborMore than 18 hours Multis 1st stage- 7hrs 20 mins 2nd stage- 30 mins 3rd stage- 10 mins Total 8 hrs Prolonged laborIf more than 12 hrs o o o o o o SECOND STAGE ( Stage of Expulsion) – full cervical dilation to delivery of the infant o STAGES OF LABOR o o FIRST STAGE (Dilatation Stage) – begins with true labor contractions and ends with full cervical dilatation o o o A. Latent phase - mild & short contraction, 20 – 40 sec; every 5-10 mins; o 3 cm cervical dilation; 6 hrs in nullipara; mother still excited, able to communicate o Station – primi 0, multi 0 to -2 o FHR heard at the level of umbilicus B. Active phase o 4 – 7 cm dilation; 40 – 60 sec contractions, stronger every 3-5 mins o 3 hrs in nullipara o show & rupture of BOW o station +1 to +2 - FHR heard slightly below umbilicus or lower abdomen C. Transiti on Phase cervical dilatation – 8-10cm UC strong , 2-3 mins apart, last for 45-90 sec copious bloody show station +2 to +3 FHR clearest at the symphysis pubis duration of this phase 1-2 hrs cervical dilatation 10cm, cervical effacement 100% UC strong 2-3 mins apart, 60-90 sec fetal descent continues at a rate of 1cm/hr in primi & 2cm/hr in multi urge to push begins perineum flattens, bulges crowning, fetus is born Mechanism of Labor Descent Flexion Internal Rotation Extension External Rotation Expulsion THIRD STAGE (Placental Stage) Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 7 NCM 107: Maternal & Child Nursing Signs of placental separation Baseline rate 120-160 BPM a) Calkin’s sign- uterus becomes firm and round in shape b) Sudden gush of blood from the vagina c. Lengthening of the cord * Delivered within 5-10 mins but not to exceed 20 mins Early Deceleration – FHB decreases at the onset of UC but returns to normal before the end of UC – head compression Acceleration – as fetus moves FHB also increases 15 bpm for 15 sec is normal MATERNAL & FETAL ADAPTATION TO LABOR A. Maternal Adaptation moderate increase in cardiac output increase HR & RR 15 mmHg increase in BP labor prolongs normal gastric-emptying time leads to n/v increase WBC as high as 30,000/mm3 urine specific gravity is high Abnormal FHB pattern Tachycardia –161-180 bpm (mild fetal hypoxia, maternal fever) Bradycardia – 100-119 bpm Fetal Adaptation (Congenital heart dis) decrease in FHR by 5 bpm during a contraction increased intracranial pressure caused by uterine pressure on the fetal head petechiae or ecchymotic areas caput succedanum pressure applied to the chest helps to clear the lungs of fluids. Late Deceleration – FHB decreases during UC and do not return to normal after the end of the same contraction (uteroplacental insufficiency) Maternal Danger Signs: 1) 2) 3) 4) 5) 6) Rising or falling BP Abnormal pulse Inadequate or prolonged contractions Pathologic retraction ring Increasing apprehension Blood loss of more than 500 cc Variable Deceleration – deceleration occurring at unpredictable times during UC –(cord compression) Nursing Care Tachycardia o Normal FHR Pattern: monitor maternal vital signs Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 8 NCM 107: Maternal & Child Nursing o change maternal position o close monitoring contractions - instruct pt. to pant with contractions 2) Fetal Status - FHB, fetal lie, presentations, Bradycardia attitude, station & position o change maternal position o administer oxygen to the mother 3) Risk Assessment - ruptured membranes (nitrazine test) - vaginal bleeding o prepare for immediate delivery 4) Maternal Status - vital signs Late Deceleration Correct cause: Supine Hypotension – change maternal position Anesthesia – elevate legs, increase hydration w/ IV fluids Uterine hyperactivity - discontinue oxytocin Left lateral position Admin. Oxygen to the mother Maternal Care: Variable Deceleration NURSING CARE DURING 1ST STAGE OF LABOR a) Bath b) Encourage ambulation to shorten 1st stage change maternal position - if lasting 2 mins help mother into knee-chest or trendelenburg position c) Solid and liquid foods are avoided d) Enema e) Perineal prep and perineal shaving prepare for immediate delivery if patterns does not improve f) admin oxygen to the mother g) Advise abdominal breathing, shld not bear down or push unnecessarily NURSE’S ROLE DURING ADMISSION 1) Birth Imminence - signs: sitting on one buttocks, bearing down or grunting w/ Encourage emptying of the bladder every 23 hrs h) . Encourage Sim’s position i) Emotional support Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 9 NCM 107: Maternal & Child Nursing j) Remain attuned to the maternal psyche provide ongoing assessment promote positive coping provide supportive care Heavy or bright red bleeding Maternal reports of unrelenting pain, right upper quadrant pain or visual changes NURSING CARE DURING 2ND STAGE OF LABOR a) Position legs at the stirrups together Fetal Care: b) Instruct mother to push not pant A. Assess FHR c) Assist in episiotomy o q 1 hr during latent phase; q 30 mins during active phase; q 15 mins during the 2 nd stage o after rupture of membranes o before & after medications o before & after invasive procedures administration Primary reason: to prevent laceration Secondary reasons: prevent stretching of rectal and bladder muscles, reduce duration of 2nd stage, enlarge outlet of Types of episiotomy median & mediolateral DANGER SIGNS DURING LABOR Elevated maternal BP a) Apply Ritgen’s maneuver Low or suddenly decreased maternal BP Elevated maternal temperature Amniotic fluid is green, cloudy or foul smelling Non reassuring FHR patterns b) Newborn should be held below the mother‘s vulva to allow blood from the placenta to enter the baby’s body c) Cutting of umbilical cord is postponed until pulsation has stopped, then clamp twice an inch apart then cut in between DANGER SIGNS DURING LABOR Prolonged uterine contractions Failure of the uterus to relax between contractions Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 10 NCM 107: Maternal & Child Nursing b. Positions for pushing o Lithotomy o modified dorsal recumbent o Side-lying o Squatting o Hands-to-knees c. Preparing for Delivery of the Newborn NURSING CARE DURING 3RD STAGE OF LABOR 1) Do not hurry the expulsion of the placenta 2) Tract the cord slowly, winding it around the clamp until placenta comes out (BrandtAndrew’s method). Note time 3) Check for completeness of cotyledons 4) Palpate uterus to determine degree of contraction 5) Inject oxytocin (Methergin 0.2 mg/ml). Shld not be given before placental delivery to NURSE’S ROLE DURING THE 2ND STAGE OF LABOR prevent placental entrapment 6) Inspect perineum for lacerations 1. Promoting effective pushing despite fatigue 7) Perform perineal care h. Position flat on bed to prevent dizziness 2. Reduce risk for trauma 8) Give initial nourishment a. Effective pushing technique o open-glottis pushing o urge-to-push method PAIN MANAGEMENT TECHNIQUES Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 11 NCM 107: Maternal & Child Nursing I. Nonpharmacologic Interventions A. Comfort measures- Relaxation techniques 1) Patterned breathing 2) Attention focusing/imagery b. Prostaglandins ( Cytotec, Cervidil) 3) Movement & positioning o used to stimulate UC 4) Touch & massage – effleurage o used in pregnant women to ripen or soften the cervix o used to control uterine atony o may be given orally, rectally or vaginally 5) Water therapy 6) Hypnosis 7) Acupressure & acupuncture PHARMACOLOGIC INTERVENTIONS Major adverse side effects : Maternal o Hypertonic uterus/uterine rupture o N/V, diarrhea a. Oxytocics (Pitocin, Syntocinon) Nursing Care: o used to stimulate UC o used to induce labor o exert vasopressor and antidiuretic effect o used to control uterine atony o Monitor UC o Have oxygen and resuscitative equip. ready Maternal Analgesia and Anesthesia Nursing Care Opoids Analgesics o Monitor client continuously o Use infusion-control device for IV admin Monitor UC o IV, IM, Epidural, intrathecal o Assess BP and PR every 15 mins. o Given during active labor o Maintain fetal monitoring o o Have oxygen and emergency resuscitation equip. available Administration timed to allow metabolism and excretion before birth to avoid resp depression on the newborn a. Meperidine HCL (Demerol) Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com) lOMoARcPSD|21943190 12 NCM 107: Maternal & Child Nursing Naloxone (Narcan) – used to counteract resp. depression o If hypotension occur, position mother on left side, increase iv infusion, admin oxygen o Assess FHR Additional Notes: b. Butorphanol (Stadol) o IM, 30-40 times more potent than Demerol o does not interfere with labor o less neonatal depression c. Nalbuphine (Nubain) o IV, IM d. Fentanyl (Sublimaze) - IV, IM, epidural, intrathecal o 100 x more potent than Demerol o min. resp depression Regional Analgesia & Anesthesia Epidural: maybe used during labor, cs Spinal: maybe used during labor or anesthesia during cs - inj. Into subarachnoid space, single dose Local Infiltration: used during episiorrhaphy Nursing Care o Observe mother & newborn for resp. depression o Monitor BP for maternal hypotension Pula, Kyle Vincent P. | BSN 2-D Downloaded by wa fugee (sebastian.nanglegan@gmail.com)