Module 2 - Womens Health

Module 2: Labor & Birth and Management of Labor Discomfort Labor, Part 1 – The Mechanics Every story counts • • • Listen to each other There is a place for • expert knowledge • evidence-based practice • The lived experience of anyone who has experienced pregnancy or birth as • The one giving birth • The attendant • The witness There is a strong need for nurses to provide perspective, context and to clarify meaning around other peoples’ labor and birth experience Knowledge is power. That is particularly true with birth. Nurses know birth differently from the way that women experience it themselves; we know things about the process and about the birth environment that we work in, that is mysterious or simply unknown to the people who come to us for care. We have an important job to share our expert knowledge and what we know from evidence based care with women who we interact with who are pregnant or laboring, or postpartum. But there is also the knowledge that stems from experiencing birth as the mother, or the support person. The things you learn from these experiences is also important. We need to recognize that almost everyone at a birth has some lived experience that affects their interpretation of what is happening. Often things we learn or hear from other people causes one to question their intuition. Often the more mothers and family members know about the process, the more likely there is to be conflict surrounding the event, because, especially in the hospital environment, there are power differentials between the patients and staff and nurses and midwives and doctors that all need to be negotiated in the midst of someone laboring! There can be struggles when the woman wants a particular kind of care or experience and her care providers are either unwilling to provide that kind of care, or recognize that the circumstances make those choices inappropriate. I am actually describing the politics of birth (politics being the way we make decisions in groups, or other forms of power relationships that govern the distribution of resources). We can’t avoid these politics, in fact, as nurses we are often the political brokers of power. Please listen to women and families and always treat them in ways that convey to them that to you, their story counts. Start from there, and share your perspective on what is going on and what might help them have the best birth outcomes, both physically and emotionally. Always be on the side of your patient. Components of a Vaginal Exam: 1. 2. 3.    Dilation Effacement Station The three things we are always measuring when we put our fingers inside of a vagina and reach for the cervix. o In a non-pregnant women, feels a bit like a nose We do this exam to assess labor progress Whiteboards dry erase boards where they will record the vaginal exams for all the patients o there will be three numbers there, it'll be it might say three\ 100\ minus one and that would be dilation of basement and station Dilation - How dilated the cervix is Starts at 0cm (closed) 10 cm is full dilation Effacement - - - Thinning of the cervix Start out with the cervix that's usually about 2 and a half centimeters long Unripe vs ripe o Unripe cervix feels like an unripe banana (solid and hard) o Ripeness = being ready for labor Cervix is going to soften and start thinning out during labor o as contractions happen this and various hormones affect the tissues of the cervix the cervix is going to soften and start thinning out Effacement process is in percentages A – 0% effaced, B – 50% effaced, C – 80% effaced, D – 100% effaced When 0% effaced, somebody whose internal OS of the cervix is still completely closed and they are fixed Station • • • • Station describes the level of the presenting of the baby part in the pelvis. It is estimated in centimeters from the level of the ischial spines in the mother’s pelvis, which is considered “Zero station” • When the presenting part of the fetus is at zero station, we say it is “engaged in the pelvis” Minus stations are ABOVE the ischial spines. • Minus 1 = 1 cm above the ischial spine, etc. • Once we get at minus 3, we would call that out of the pelvis • Laudable = we can bounce that baby around in the pelvis, out of the pelvis, in the abdomen, and with a tap of our fingers that we can change the baby's position • When a baby is engaged in the pelvis, their head is fixed there and a little tiny tap from a finger during a vaginal exam is not going to budge that baby at all nor will a little tap through the moms abdomen change the baby's position Positive stations are BELOW the ischial spines. • As the baby moves through cardinal movements of birth, we're going to see that the station increases True Labor requires these two things: 1. Regular Uterine Contractions • Where the uterus is tightening the muscle is tightening around itself 2. Cervical change • those contractions are strong enough that they are moving muscle fibers and creating cervical change Somebody may have been having contractions every two minutes for the last seven or eight hours and it might not be true labor and we would call it false labor if their cervix is exactly the same at the end of those hours as it was at the beginning Cervical dilation, effacement and station Process of Labor – The 5 P’s 1. Passage a. Pelvis type: gynecoid and anthropoid are good; platypelloid and android are not so good 1. Shape of the bone b. Soft tissues: Cervix, Vagina, Perineum, Tone of Pelvic musculature 1. Pelvic musculature - Once you have a baby, your pelvic muscles will remember and you will have a shorter labor than your first baby 2. Passenger a. The cardinal movements of the fetus b. The fetal head (how big is it and how its positioned in the pelvis) c. The presenting part: cephalic (vertex) or breech (frank, complete, footling) d. The fetal lie: vertical or transverse or oblique e. The fetal attitude/posture: flexed or extended (e.g. brow presentation) f. The size of the fetus 3. Powers (involuntary contractions and secondary powers to “push the baby out”! 4. Position: maternal position in relation to the fetal position 5. Psyche: of the pregnant woman, her support people and healthcare providers • The Passage: Important pelvic landmarks • • False pelvis is the area within the entire pelvic “girdle” True pelvis is the area below the pelvic brim • Pelvic inlet – the beginning/top/opening of the tunnel that the baby has to put its head through Pelvic outlet – the other end of the tunnel Passage: the bony pelvis • Gynecoid. This is the most common type of pelvis in females and is generally considered to be the typical female pelvis. Its overall shape is round, shallow, and open. • • • • The gynecoid pelvis is thought to be the most favorable pelvis type for a vaginal birth. This is because the wide, open shape give the baby plenty of room during delivery. • Easiest, most suitable for cb is Gynecoid – nearly half of all Caucasian women have this shape Android. This type of pelvis bears more resemblance to the male pelvis. It’s narrower than the gynecoid pelvis and is shaped more like a heart or a wedge. • The narrower shape of the android pelvis can make labor difficult because the baby might move more slowly through the birth canal. Some pregnant women with an android pelvis may require a C-section. • Labors may be longer with vaginal birth Anthropoid. An anthropoid pelvis is narrow and deep. Its shape is similar to an upright egg or oval. • The elongated shape of the anthropoid pelvis makes it roomier from front to back than the android pelvis. But it’s still narrower than the gynecoid pelvis. Some pregnant women with this pelvis type may be able to have a vaginal birth, but their labor might last longer. Platypelloid. The platypelloid pelvis is also called a flat pelvis. This is the least common type. It’s wide but shallow, and it resembles an egg or oval lying on its side. Hard to get a baby through it. • The shape of the platypelloid pelvis can make a vaginal birth difficult because the baby may have trouble passing through the pelvic inlet. Many pregnant women with a platypelloid pelvis need to have a C-section. Passage – Pelvimetry      How we figure out the shape of the pelvis = pelvimetry When a woman comes in for her new OB visit and the midwife or physician does a vaginal exam, we aren't doing that vaginal exam for to check dilatation, effacement, and station unless she's really far along in the pregnancy o we are doing pelvimetry and we are checking the size of her uterus by putting a hand on top of her belly too and doing a bimanual exam (where you have one hand in the vagina or fingers in the vagina and a hand on the belly) We're taking measurements with our fingers and we're measuring these diameters to see if we can estimate what kind of a pelvis that the woman has and whether it's likely to accommodate vaginal birth or not It is a rough estimate of actual pelvic shape X rays aren't really that helpful pelvimetry because of 3D Passenger = Fetus – The Second “P” • • • • Fetal size • The size of the baby makes a difference in how quickly labor progresses Fetal Skull • The dimensions makes a big impact on how quickly labor progresses Fetal Position • Fetal Lie – longitudinal, transverse (going across left to right) or oblique (diagonal) • Fetal presentation – vertex/cephalic (head first), breech (butt first), shoulder, compound (vertex and hand), and funic (umbilical cord). • Attitude – degree of flexion or extension of the fetal head (how curled or flexed vs how extended or stretched out) The Cardinal Movements of the fetus • How the baby moves through the pelvis Important landmarks of the fetal skull 1. Occipital bone 2. Posterior fontanelle 3. Anterior fontanelle 4. Biparietal diameter 5. Suboccipitobregmatic The largest transverse diameter of the fetal head is the biparietal The smallest anteriorio-posterior diameter of the fetal skull is the suboccipitobregmatic The suboccipitobregmatic diameter is the most important one because when the head is completely flexed it is the presenting diameter in the pelvis. If the head is more extended, the AP diameter of the skull widens, making it harder for the head to enter the pelvis.  Vast majority of these babies are going to be vertex or head first     Frank breech = legs are completely extended and the buttocks are presenting first but the legs are up by the head Full breech = the baby's buttocks are still what's the presenting part but the feet because the knees are bent the feet are like down dangling near the buttocks Footling breech = you can have either a single footling breech, where the foot is coming first or a double footling breech where both feet are coming out first it's also possible for a face to be what's presenting instead of the vertex or top of the head the face it could be the brow or it could be a shoulder   How flexed or extended they are We are demonstrating how it is that that suboccipitobregmaticsis only 9.5 centimeters The Passenger Fontanelles and Sutures are used to figure out attitude:  The fontanelles and sutures are used to figure out the position of the baby (the attitude) o it's where is the posterior fontanelle in comparison to the diamond shaped anterior fontanelle triangle diamond  When we do a vaginal exam ,that's what you're seeing on the bottom      You can see how you're feeling posterior or anterior fontanelles to figure out whether you've got a baby that is like on the left completely flexed, so all you're really it's very hard to feel that anterior fontanelle is it so far forward on the mothers right In a moderately flexed baby, you're going to have the ability to feel that anterior fontanelle Then if it's a really poorly flexed baby you're going to be feeling it closer to the side that the baby's back is on The more extended the baby is you're going to be feeling this anterior fontanel on the side that you can palpate abdominally, the fetal back finally we've got to face presentation here where you can't feel any fontanelle Leopold’s Maneuvers How do we find out where the baby’s back is? - Leopold’s Maneuvers is a systemic way to figure out the position of the baby - We don't do it until after 24 weeks because the baby is too small that actually make out the fetal parts in most women - The more the woman ways, the harder it is o If someone is obese, then it is tricky even at term Performed after 24 weeks in order to determine the position of the fetus inside the woman’s uterus in four steps 1. Fundal grip  You start out by taking both your hands and putting them on the top of the woman fundus (top part of her uterus)  We feel the fundus and we ask ourselves: is this hard or soft? if it is squishy, than we think we've got a butt and if it is hard like a skull, then we think we have a head  If it doesn't if we can't really get our hands on anything, we wonder is this baby transverse  and we might find the squishy thing or the soft thing just slightly off to the side in which case we're going to expect the baby may be oblique but we're going to confirm that with our next step 2. Determine which side has small parts  We're moving our hands down the sides but the woman's abdomen and feeling for the side that is smooth and relatively hard, which is the side of the back versus the other side that's going to have bumps (it's going to be bumpy and lumpy and more in some