Maternal Newborn Labor & Delivery

! ! ! ! ! ! ! Maternal Newborn Labor & Delivery Physiological changes that precede labor True vs. False Labor Backache True Labor: Contractions that may start Weight loss (1-3 pounds) irregularly, but become stronger, more Lightening (feeling that baby frequent, and regular. Walking increases has dropped lower in pelvis.intensity of contractions. Comfort measures Contractions (irregular (oral hydration, bladder emptying) do not Braxton Hicks contractions that stop contractions. Cervical changes present become stronger and more (dilation, effacement, blood show). Presenting regular) part of fetus engaged in pelvis. Bloody show (brown or bloody mucus discharge) False Labor: Painless, irregular, intermittent Energy burst contractions. Walking or position changes GI upset decrease intensity/duration of contractions. Rupture of membranes (clear, Comfort measures (oral hydration, bladder water fluid; Amniotic fluid will emptying) often stop contractions. No cervica cause Nitrazine paper to turnchanges. Presenting part of fetus not engaged BLUE, paper remains yellow inwith pelvis. urine) ! ! Stages of Labor FIRST STAGE: begins with onset of labor, ends with complete dilation. Latent phase: Cervix 0-3cm; mild to moderate contractions; mom is talkative and eager. Active phase: Cervix 4-7cm; moderate to strong contractions; mom is anxious, restless, feeling helpless. Transition: Cervix 8-10cm; strong to very strong contractions; mom feels need to push or have a bowel movement (i.e. rectal pressure), feels like she “cannot continue”. Second Stage: Full dilation to birth of baby. Third stage: Delivery of baby to delivery of placenta. Fourth stage: Delivery of placenta to stabilization of maternal vital signs. ! ! ! ! 5 p’ s Passenger: • • • ! ! ! ! Passageway: Powers: ! ! ! — Passenger — Passageway — Powers Consists of fetus and placenta. Presentation (head, chin, shoulder, breech) Lie (transverse, parallel/longitudinal) Position: Label with three letters Position: Birth Canal Uterine contractions, resulting in effacement, dilation. — Position — Psychological response Upright, sitting, kneeling, squatting promotes fetal descent. Psychological response: Stress, anxiety can impair labor. Pain management during labor Non-pharmacological: Pharmacological: EFFLEURAGE: • Stroking of mom’s abdomen with SEDATIVES • (BARBITURATES): can lead to neo fingertips during contractions. respiratory depression. Use only in early or latent SACRAL •COUNTER-PRESSURE: heel of hand phase. or fist is pushed against mom’s sacral area to relieve OPIOD• ANALGESICS: can lead to sedation, back labor pain. tachycardia, hypotension, decreased FHR variability OTHERS: • breathing techniques (start with neonate respiratory depression. Naloxone is cleansing breath), imagery, hydrotherapy, music,antidote. Use when cervix is dilated at least 4cm heat/cold. and fetus is engaged. ! ! ! Epidural Block Spinal Block Eliminates sensation from umbilicus Eliminates sensation from nipples to to thighs. Administer when mom is feet. Used in cesarean births. at least 4cm dilated. Side • effects: maternal hypotension, • Side effects: maternal fetal bradycardia, headache from hypotension, fetal bradycardia leakage of CSF, risk of maternal bladder and uterine atony. ! Nursing Care: Administer IV fluids (to offset maternal hypotension), position m on side (to prevent supine hypotension syndrome), monitor maternal vital signs FHR continually. ! Fetal Assessment Leopold Maneuvers: Palpation of the Expected findings for Fetal Heart Rate (FHR): uterus through the abdomen to determine — Between 110-160 beats/min the presenting part, fetal lie, fetal attitude, — Moderate variability and point of maximal impulse (PMI). Used— Accelerations present or absent to determine placement of external — Early decelerations present or absent transducer for fetal monitoring. — NO variable or late decelerations Fetal Heart Rate (FHR) Patterns Accelerations: Temporary in FHR above baseline. — Reassuring — No intervention necessary. Fetal Bradycardia: FHR <110/min for >10 min. — Due to uteroplacental insufficiency, umbilical cord prolapse, maternal hypotension, anesthetic meds. — D/C oxytocin, place patient in side-lying position, administer oxygen, notify provider. Fetal Tachycardia: FHR >160/min for >10 min. — Due to maternal infection, cocaine use, dehydration — Administer antipyretics, oxygen, IV fluid bolus. Early deceleration: Slowing of FHR with start of contraction. — Due to compression of baby’s head from contraction. — No intervention necessary. Late deceleration: Slowing of FHR after contraction has started and prolonged return to baseline. — Due to uteroplacental insufficiency. — Place patient in side-lying position, administer IV fluids, d/c oxytocin, administer O2, palpate uterus for tachysystole, notify provider. Variable deceleration: Transient, variable slowing of FHR. — Due to umbilical cord compression. — Place patient in knee-chest position (or reposition from side to side), d/c oxytocin, administer oxygen. ! ! ! internal fetal monitoring Internal fetal monitoring: Scalp electrode attached to the presenting part of f monitor FHR. Can be used with IUPC (intrauterine pressure catheter). Allow accurate assessment of FHR and uterine contractions. Average pressure of c 50-85 mmHg. Disadvantages: Membranes must be ruptured, cervix dilated >2cm, and pres descended to use internal monitor. Risk of injury to fetus, and risk of infecti baby. ! ! External Cephalic Version (ECV ECV: Ultrasound-guided manipulation of the abdominal wall to turn a baby in a breech or transverse position to the normal vertex presentation (i.e. head-down position). Performed after 37 weeks gestation. HIGH risk of umbilical cord or placental abruption. Nursing Care: If mom is Rh-negative, ensure RhoGAM was administered at 28 weeks gestation. After ECV, perform Kleihauer-Betke test to detect fetal blood in maternal circulation (if >15ml present, administer additional RhoGAM. Administer IV fluids and tocolytics to relax uterus. Continually monitor FHR, maternal vital signs. • • ! ! ! ! Induction of Labor Cervical ripening: Promotion of cervical softening, dilation, and effacem Examples: ballon catheter, membrane stripping, dilators, chemical agen (ex: misoprostol, dinoprostone) administered orally or vaginally. Oxytocin: Uterine stimulant. Increases strength, frequency, and length of uterine contractions. — Closely monitor contractions and FHR. — D/C oxytocin for contractions that occur more frequently than every 2 minutes, contractions lasting more than 90 seconds, contraction intensity greater than 90mmHg w/IUPC, or uterine resting tone greater than 20mmHg between contractions. — Administer terbutaline to decrease uterine activity. ! ! ! ! Amniotomy and Amnioinfusion Amniotomy: Rupture of amniotic membranes by Amnioinfusion: Infusion of NaCI or LR into amnio provider, using a sharp instrument. cavity. Indications: • Induction or augmentation of labor, orIndications: in • Oligohydramnios, fetal cord compre preparation for amnioinfusion. (causing variable decelerations). Increased • risk for cord prolapse (ensure presenting Nursing • Care: Assist with amniotomy (if part of fetus is engaged prior to amniotomy) and infection. membranes not already ruptured) prior to infusion. ! Vacuum & Forceps Assisted Delivery Vacuum: Traction applied to fetal head using cuplike suction device. Baby must be in vertex presentation. — Indications: Maternal exhaustion or ineffective pushing. — Increased risk for maternal lacerations, infant subdural hematoma, cephalohematoma, caput succedaneum (should resolve in 3-5 days). Forceps: Traction applied using curved spoon-like blades to assist in delivery. — Indications: Abnormal fetal presentation, fetal distress. — Increased risk for perineum lacerations, bladder injury, facial bruising or nerve palsy in infant. ps rce o F ! ! ! ! ! ! m cuu a V Prolapsed Umbilical Cord ! ! ! ! What is it? Umbilical cord protrudes through cervix ahead of the baby, causing cord compression and compromising fetal circulation. Nursing Care: — Call for assistance FIRST — With a sterile-gloved hand, insert two fingers into the vagina (one on either side of the cord) and elevate the fetal presenting part off of the cord. — Reposition mom in a knee-chest or trendelenburg position. — Apply warm, sterile, saline soaked towel over cord. ! ! ! Meconium-Stained Amniotic Fluid Nursing Care: Meconium-Stained amniotic fluid: Often present in breech presentation. • • for possible neonatal resuscitation at birth. Higher risk after 38 weeks gestation. • May indicate fetal hypoxia. Stained fluid Arrange for equipment and resources needed • If respirations are depressed, muscle tone with variable or late FHR decelerations is decreased, and heart rate <100/min, suction an ominous sign. below infant’s vocal cords with ET tube before spontaneous breaths occur. ! ! What is it? Difficult or abnormal labor due to uterine Dystocia abnormalities, cephalopelvic disproportion, fetal Nursing Care: malpresentation. Signs & Symptoms: ! ! Insufficient progress in ! dilation, effacement, or fetal ! ! descent during labor. ! ! ! Encourage position changes and ambulation. Assist with amniotomy. Provide oxytocin as prescribed. For shoulder dystocia, apply suprapubic pressure. Position patient on hands and knees to help rotate fetus from a posterior to anterior position. Prepare for possible forceps-assisted, vacuum-assisted or cesarean birth. ! what is it? Labor Precipitous Labor that lasts less than 3 hours from onset of contractions to Risk factors: Hypertonic uterine contractions, oxytocin, multiparous patient. time of delivery. Complications: maternal lacerations, tissue trauma, uterine rupture, amniotic fluid embolism, postpartum hemorrhage. Fetal hypoxia due to hypertonic contractions, intracranial hemorrhage due to head trauma. ! ! ! ! ! ! ! Uterine Rupture Risk factors: Trauma, Signs & Symptoms: Patient reports of “ripping” o overdistension of uterus, “tearing” and sharp abdominal pain. Non-reassuri hyperstimulation from (bradycardia, variable or late decelerations, decrea oxytocin, multigravida variability). Signs of hypovolemic shock (tachyca patients. hypotension, pallor). Nursing Care: Administer IV fluids, blood as prescribed. Prepare patient for with possible hysterectomy. Amniotic Fluid Embolism what is it? Infiltration of amniotic fluid into maternal circulation, which travels to and obstructs pulmonary vessels. Leads to respiratory distress and circulatory collapse. ! Signs & Symptoms: Sudden chest pain dyspnea cyanosis tachycardia hypotension bleeding. ! ! ! Nursing Care: Administer O2, IV fluids, blood products as prescribed. Assist with intubation and mechanical ventilation as indicated.