Labor and Delivery
Jenn PILTAWER
Client Care
▶
As a labor and delivery nurse, who
do we care for?
WRITE IT DOWN! HAND IT IN.
▶
WHAT IS LIGHTENING? (Yep, it’s spelled correctly)
▶
Think for a moment:
▶
SIGNS AND SYMPTOMS THAT A
WOMAN HAS EXPERIENCED
LIGHTENING
What is the TRUE Pelvis?
Again, ATI states 30 weeks
Remember,
ATI states it’s
18 weeks.
WHAT DO YOU REMEMBER?
Find a lil’ buddy for a chat :)
TRUE LABOR
FALSE LABOR
Cervix
Anterior Cervix
Posterior Cervix
Mucous Plug
and Bloody
Show
Bloody Show
Contractions:
False Labor versus True Labor
FALSE LABOR:
True LABOR
Which strip shows a higher likelihood of
TRUE LABOR?
Labor
SROM/AROM
Prolonged Rupture
(ROM)
SROM
Fetal Tachycardia
then Maternal Fever
Assessment of Fluid:
color/odor
PROM vs. PPROM
Rupture of
Membranes (ROM)
▶ COMFORT MEASURES
▶ CLIENT EDUCATION
▶
Fluid leakage is constant (ALL amniotic fluid did not leak out of sac at once)
▶
Oral Temperature after ROM
▶
How often?
▶
Marsha calls you (the nurse at the doctor's
office) and tells you she might have broken her
‘bag of water.’ She tells you that she had a
large gush of fluid but now she feels a ‘small
trickle occasionally.’
▶
As the nurse, what are the 3 PRIORITY questions you
need to ask Marsha during your phone conversation?
The case of
Shaunie:
Shaunie is a 41 year old G3 P2 with an uncomplicated
pregnancy. History of 2 previous term vaginal deliveries.
She arrives in obstetrical triage and states she “does not
feel well”. You place the external fetal monitor and Toco
on her abdomen; you note the fetal heart rate baseline is
185 bpm, minimal variability, no accelerations and no
decelerations. Next, you check Shaunie's vital signs; BP
118/71, Pulse 101, oral temperature 39 celsius, RR 19. You
ask Shaunie if she has noticed any leaking of fluid from
her vagina and she tells you she’s been leaking for 4 days
but thinks it is urine.
1. As the nurse, what would be your next
assessment?
2. What do you suspect is the issue?
3. When speaking with her provider, what orders to
you recommend in the treatment of this client?
Maternal
Temperature:
S/S of
Chorioamnionitis:
Case Study: Group
Work
Find a buddy & write
down assessment
concerns & Nursing
actions
Karen’s BOW (bag of water) ruptured 26 hours ago.
She is laboring on a labor and delivery unit and she is
5cm dilated. Her partner is lovely and brought her a
giant cup of ice chips; just as she finishes consuming
this cup of ice, her nurse comes to the bedside to
assess maternal vital signs and fetal heart rate. Karen
tells her nurse that she feels a bit nauseous. Karen’s
vital signs are as follows:
Temperature: 35.8 c (96.4 F)
HR: 97
BP: 80/49
FHR Interpretation:
FHR 175, Moderate variability, no accelerations, no
decelerations noted
Questions to Consider:
What does the nausea mean?
How soon after SROM/AROM would we like
Karen to deliver?
If Karen’s BP remains low, what changes in
the FHR would we expect to see?
What stage of labor is she experiencing?
Phase?
What should Karen’s nurse ask prior to
checking her temperature?
▶ What is the NORMAL (ATI) maternal
temperature range?
▶ Why do you think Karen’s temperature is
considered low?
Questions to
Consider:
▶ What are you, the nurse, going to do
about Karen’s temperature?
▶ What is considered a NORMAL Fetal Heart
Rate (FHR)?
▶ Is this a normal FHR?
Questions to Consider:
▶ How do you interpret fetal tachycardia? Exactly, what does it
mean?
▶ What category does this FHR strip fall into?
▶ What are your nursing interventions regarding the FHR?
Chorioamnionitis (aka: “Chorio”)
▶
You were an awesome nurse and immediately turned Karen to her
left side. Once positioned on her side, the nausea disappeared
and her BP increased to 110/71 (back to her baseline). Karen has
been NPO for 15 minutes and you recheck an oral temperature;
the thermometer reads 39 degrees Celsius (102.2 F). The FHR
remains 175, moderate variability, no accelerations, no
decelerations noted
▶
What is your priority nursing action at this time?
▶ What orders do you anticipate her provider ordering?
“Chorio”
▶ What medications do you
anticipate Karen's provider
will order?
Intrapartum Nurse:
What do we assess?
Maternal Wellbeing
Fetal Wellbeing
The 5 P’s
View this
PREZI
and
VIDEO
PASSAGEWAY
PASSENGER
POWERS
Frequency
Duration
Intensity
POSITION
Psychological Response:
Cycle of pain
▶
▶
▶
▶
▶
▶
FEAR
FATIGUE
FULL BLADDER
FETAL MALPOSITION
LEVEL OF SUPPORT
Childbirth Classes
VIDEO
Locate the following:
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External Rotation
7. Birth
MECHANISM OF LABOR IN
VERTEX PRESENTATION
Write down your thoughts…
Renita is a G2P1. She has been 6/70/-2 for 7 hours.
She has an epidural and prefers left side-lying position
only. Her fetus is LOP. Her first child weighed 9 lbs 1 oz.
She is contracting every 3 minutes.
What Stage of labor is she in?
▶ What phase?
▶ After reviewing the 5 P’s, what P’s do you believe could be
responsible for this prolonged stage/phase of labor? Explain.
▶ What nursing interventions would you consider regarding the
P’s responsible?
▶
Gate- Control Theory:
Think-Pair-Share
▶
What is the Gate-Control Theory?
▶
Name 2 SENSORY stimulation strategies
▶
Name 2 CUTANEOUS stimulation
strategies
SACRAL COUNTERPRESSURE
How does
counter pressure
work?
Pharmacologic Interventions
▶
SAFETY is FIRST PRIORITY!!!
▶
Assess verbal and non-verbal cues to determine if pain
level is improving
Pharmacological Pain Management
Sedatives (Barbiturates)
Opioids
-Barbital
Fentanyl, Dilaudid
▶
What are they used for?
▶
How do we administer this drug?
▶
When would we administer this
drug?
▶
What are the adverse effects of
this drug?
▶
Why?
▶
Name the opioid antagonist
▶
Nursing Interventions/Client
instructions once the drug is
administered…
Nursing Interventions/Client
instructions once the drug is
administered…
▶ My client received a Sedative
after umbilical cord was cut*
▶
Let’s think….
▶
If the pregnant client has nausea
&/or vomiting, what is my 1st
nursing action?
EPIDURAL BLOCK: PCA Education
Pudendal Block
Pudendal BLock
Continued....
Broad Ligament
Hematoma
Nursing diagnosis…
RR
BP
FHR
Epidural Block
Epidural Block
Positioning for Epidural and Spinal
Placement: Nursing Actions?
Epidural Block Cont…
What would you do?
▶
Andrea is a 16 year old G1P0. She is 5 cm dilated. She has been working with
a doula since she began painfully contracting 14 hours ago. The doula has
been assisting Andrea with breathing exercises, position changes and
massage. Andrea is now screaming with each contraction; when the
contraction ends, she looks at you, the RN, and says, “I need my epidural
NOW.” You leave the room to contact Andrea’s provider when her father
stops you and says, “Andrea may NOT have an epidural. She has caused our
family a lot of pain with this pregnancy and now she has to pay the price.”
▶
How do you respond?
▶
Think about Andrea’s age; can she make this decision without a parent’s
permission?
Spinal Block
▶
Spinal Headache
▶
S/S
▶
When does this occur?
▶
Anticipated Nursing Actions
▶
What is a blood patch?
What would you do?
Kristen, G1 P0, arrives in labor and delivery 4cm
dilated with SROM. The moment Kristen and her
spouse enter the room, they hand you a birth plan.
It specifically states that Kristen does NOT want the
word ‘PAIN’ or ‘PAIN MEDICATION’ mentioned at all
during her labor.
▶ How do you monitor her pain level?
▶ What will you chart?
▶
Two hours later, Kristen found to be 7 cm dilated;
she is crying and begging you to get the
anesthesiologist for an epidural. Kristen’s spouse
leans over to her and says, “honey, remember what
you told me? You said that if you ask for an
epidural, I need to stop you. So, I’m sorry. You can’t
have an epidural.” Kristen continues to cry and says
that she has changed her mind. Her spouse
continues to refuse her.
▶ What do you do?
▶
General Anesthesia
▶
Why do we only offer ICE CHIPS to our laboring
patients?
▶
DVT Prevention
▶
Why does the healthcare team administer Oral
Antacids, Zantac (IV) and Reglan (IV) prior to a
cesarean section and/or general anesthesia?
Partial Voice-over: Click HERE
Voice-over
in progress….
Zoom
Lecture
5: Click HERE
(Go to 1hour 46 minute mark to begin) Topics: Lightening, True vs False Pelvis, Fundal height
measurement, True vs false labor, cervical effacement vs dilation, mucous plus vs bloody show
Zoom Lecture 2: Click HERE
Topics: Mechanisms of Labor, 5p’s, Gate-control theory of pain, Pharmacologic Interventions, Epidural,
spinal, pudendal block
Zoom Lecture 3: Click HERE
Cervical Effacement & Dilation, Anterior vs. Posterior cervix (Bishop Score), Cervical Ripening, Mucous
Plug, Bloody Show, False vs. True labor, ROM (SROM vs AROM), IFE, IUPC, Chorioamnionitis, Meconium
stained fluid, Intrapartum RN, 5P’s
Zoom Lecture 1:Click HERE
Topics: Pain management scale, General Anesthesia, Magnesium Sulfate, PPROM, ECV, Terbutaline