N 106 Labor and Delivery

N 106Labor and Delivery

Female external genitals

L&D- the P’s of Labor

• Poweruterine contractionsmaternal pushing

• Passagebony boundaries of pelvissoftening of cartilage linking pelvic bones

• Passengerlie attitude presentation

occiputbrow, faceshouldersacrum

position – LOA,ROP• Psych

Uterine muscle layers. Muscle fiber placement.

POWER

Pelvic types: gynecoid, android, anthropoid, platypelloid

PASSAGE

Typical anteroposterior diameters of the fetal skull.

PASSENGER

LIE• The relationship of

the long axis of the fetus to the long axis of the woman

• 99% the lie is longitudinal and parallel

• Transverse lie – fetus is at right angle to mother

Transverse lie - uncommon

ATTITUDE

Fetal attitude is the relationship of fetal body parts to itself.

flexed extension

Flexion is normal

PRESENTATION

Cephalic Vertex presentation.

Breech presentation.

The fetal part that first enters the pelvis

Cephalic presentationsOcciput/vertex

Military

Brow

Face

Breech presentations

Frank Breech

Full Breech

Footling Breech

Position

• Fetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis

• Abbreviations of presenting part is “cuddled” between maternal pelvis

• LOA, LOP, ROA, ROP, RSA, LMP• Occiput, Sacrum, Mentum (chin), Anterior,

Posterior

Categories of presentation.

A B C D

Quiz

PSYCHE

• Preparation and information

• Anxiety and fear decrease coping

• Culture affects views

• Both physical and emotional experience

• Do not “nurse the machines”

L&D nursing responsibilities

• HistoryAntepartal

weight gainfetal gest & growthrisk factorspresent status

• Obstetrical• Medical surgical• interval

• Assessmentmaternal

vital signsuterine activitybladder status I&Obloody showresponse to labormaternal

discomfortfetal

heart rateAmniotic fluid

L&D Leopold’s maneuvers

• Palpate upper abdomen

• Palpate opposite side in circular motion for fetal extremities

• Palpate for engagement of presenting part

• Palpate to identify cephalic prominence

What fetal part is in fundus

Palpate for back

Palpate for engagement of presenting part

Palpate position of head –

determine descent & flexion

Location of FHR in relation to the more commonly seen fetal positions.

Location of FHR in relation to the commonly seen fetal position

Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The ultrasound device is placed over the area of the fetal back.

Intrapartum Fetal Assessment

• Fetal Heart Rate

• Electronic Fetal Monitoringultrasound transducer

• Response to contractionstocotransducer

• Internal fetal monitoring – RBOW

fetal scalp electrodeintrauterine pressure catheters (IUPC)

Attached spiral electrode with the guide tube removed.

Characteristics of uterine contractions.

Normal fetal heart rate pattern obtained by internal monitoring.

Fetal Heart Rate Patterns

• Tachycardia – greater than 160 for 10 min

• Bradycardia – less than 110 for 10 min

• Absent or minimal beat-to-beat variability

• Early decelerations – head compression

• Late decelerations – uterine placenta insufficiency

• Variable decelerations – cord compression

Comparison of labor patterns. A) Normal uterine contraction pattern. B) Hypotonic uterine contraction pattern..

A

B

Types and characteristics of early, late, and variable decelerations.

Nursing Interventions for Decelerations

• EarlyContinue to observe

• LateStop oxytocinReplace fluidsChange mother’s positionCheck B/P and PulseAdminister oxygenNotify physician

• VariableStop oxytocinReplace IV fluidsChange mothers positionCheck for prolapsed cordCheck B/P and PulseAdminister oxygenNotify the physicianPrepare to assist with fetal scalp blood sample

Conditions Associated with Fetal Compromise

• FHR below 100 or above 160

• Amniotic fluid Meconium-stained (greenish) Cloudy, yellowish, or foul-smelling

• Contractionslasting longer than 90 secondsoccurring less than 2 minutes apart

• Maternal hypotension, hypertension, fever

Actions to increase oxygen to fetus

• If receiving Pitocin stop or slow rate

• Reposition mother

• Increase non-additive IV fluids

• Administer 100% oxygen thru snug face mask to mother at rate of 8-10 liters/min

• Keep mothers bladder empty

• Change under-pads regularly

L & D true vs false labor

• True labor contractions:Start in back & move wavelike toward abdomenBecome more intense with walkingResult in ripening of cervix, dilation & effacement

• False labor contractions:Noticed primarily in abdomenBegin & remain consistentDisappear with walkingNo change in cervical dilation or effacement

To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening.

Measuring the station of the fetal head while it is descending

Mechanism of Labor

• Engagement / Decent

• Flexion

• Internal rotation

• Extension

• Restitution

• External rotation

• Expulsion

Mechanisms of labor.

Stages of Labor

• Stage Icervical dilation to 10 cm &effacement to 100%

early/latentactivetransition

• Stage IIcrowning to birth of baby

• Stage IIIbirth of baby to delivery of placenta

• Stage IV1-4 hours after delivery of placentastabilizationrecovery

Phases of Stage I of Labor

• Early/latent - dilates - 0-3 cm contractions q 5 min X 30-40 sec

• Active - dilates – 4 - 7 cm contractions q 2-5 min X 40-60 sec

• Transition- dilates – 8-10 cm contractions q 2-3 min apart X 60-90 sec

Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.

Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.

Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.

Complete effacement and dilatation.

End of Stage 1

Friedman CurvePredicable progression of labor for

Nulliparous and Multiparous

Responsibilities during First Stage of Labor

• Promote Comfort positioning, lightingtemperature, cleanlinessbladder, mouth care

• Relieve painbreathing techniquesnonpharmacologic

massage, touch, pressure

hydrotherapyimagery or focal point

Stage 2From 10cm 100% to birth of Baby

• Assist mother with pushing

• Preparation of sterile delivery table

• Perineal cleansing

• Sutures for episiotomy or laceration

• Initial care and assessment of newborn

• APGAR

Effects of labor on the fetal head. Caput succedaneum formation.

Care of Infant

• Maintaining cardiopulmonary function – APGAR

• Supporting thermoregulation

• Identifying infant

• Examining for obvious anomalies and birth injuries

• Medication administration

Clamp is positioned 1/2 to 1 in from the abdomen and then secured.

APGAR

• Heart rate – above 100• Respiratory Effort – spontaneous with cry• Muscle tone – flexed with movement• Reflex response – active, prompt cry• Color – pink or acrocyanosis• 0-3 infant needs resuscitation• 4-7 Gentle stimulation – Narcan• 8-10 – no action needed

Cut cord. The one vein and two arteries can be seen.

Placenta SeparationStage 3

• Uterus changes shape

• Uterus rises upward in the abdomen

• Cord begins to move out of the vagina

• Gush of blood noted from vagina

Placental separation and expulsion.

Schultze mechanism.

Stage III

Stage 4 of Labor

• First 1-4 hours after delivery of placenta• Palpate fundus• Assess vital signs• Assess lochia• Ice pack to perineum• Care of infant and Care of mother• Identification• Promoting bonding

Suggested method of palpating the fundus of the uterus during the fourth stage.

Common Intrapartum Procedures

• Amniotomy

• Stimulation of laborinductionaugmentation

• Assisted deliveryepisiotomyforcepsvacuum extractor

• Cesarean delivery

Amniotomy

• Artificial rupture of fetal membranes

• Advantagesdecrease some laborassessment of fluid for meconiumpermits internal monitoring

• Riskscord prolapseinfection

Assessment of Fluid

• Quality, Color, and Odor

• Greenish, meconium stained

• Large amount of vernix

• Strong order, cloudy or yellow

• Hydramnios

• Oligohydramnios

Prolapse of the umbilical cord.

Risk during ROM

Induction & Augmentation of LaborDuring Stage 1

• Definitions• Criteria – Bishop’s scoring, 39 weeks gest.• Methods

surgical – amniotomydrugs

Oxytocin (Pitocin) – IV stimulate contractions Cervical ripening agents prostaglandin

Misoprostol (Cytotec)- tabdinoprostone (Prostin E2)

Cervidil/Prepidil - vaginal/cervical gel

Episiotomy

• Most common operationprimip – 70%multip – 30%

• Typesmidline – most common

problem with 3-4th degree lacerationmediolateral

increased PP pain, more scaringMain risk – infection Complication of infection – prolonged dyspareniaPrevention – perineal massage & stretching

beginning at 34 weeks.

Lacerations

• First degree - limited to fourchette, perineal skin, vaginal membrane

• Second degree - underlying fascia and muscle of the perineal body

• Third degree – involves the anal sphincter

• Fourth degree – extends thru the rectal mucosa to lumen of rectum

Interventions During Stage 2

• Forceps & Vacuum Extraction

• Assist with decent and rotation of fetal head

• Risk- trauma to maternal and fetal tissue

• Criteriascalp is visible at vaginal opening normal scalp ph is above 7.25Low forceps - station is +2 or lowerMid forceps - station 0 to +2

With correct placement of the blades, the handles lock easily.

Forceps

Vacuum extractor

Risks to Mother and Infant

• Motherlaceration hematoma of the vagina

• Infantecchymosesfacial and scalp lacerations and abrasionscephalhematomaintracranial hemorrhage

• Chignon –scalp edema from vacuum extractor

Cesarean Birth

• About 22% of all births

• Indications – dystocia, CPD, PIH, DM, genital herpes, prolapsed cord, fetal malpresentations, placenta previa or abruptio placentae

• Maternal risk same as any abdominal OR

• Infant’s greatest risk is lung immaturity

Preparation for C/S

• NPO, get operative permit signed• Pre-op teaching• Lab work – CBC, clotting series, type and cross

match one or more units• Single IV dose of antibiotics • Famotidine (Pepcid) and citrate (Bicitra)• Shave abdomen• Insert foley catheter• Perform abdominal scrub

Incisions for C/S

• Abdominal incisionvertical – umbilicus to symphysistransverse or bikini – above symphysis

• Uterine incisionslow transverselow verticalclassic

• Abdominal and uterine incisions do not always match

Low transverse incision

classic uterine incision

Nursing Considerations C/S

• Routine assessments q 15 min X 1 hr, q 30 min X 1 hr then hourlyVSfundus for firmness, height, deviationlochiaurine outputabdominal dressing

• Assess need for pain medication• TCDB – support incision with pillow

Intrauterine Infection

• Signs Fetal tachycardia – FHT greater than 169Maternal fever – greater than 100.4Foul or strong-smelling amniotic fluidCloud or yellow appearance to amniotic fluid

Nursing Care for Infection

• Preventionwash handslimit vaginal examinationskeep under pads dry

• Assess VS q 4 hours if ROM than q 2 hrs

• Collect culture specimens

Intrapartum complications

• Dystocia

• CPD – cephalopelvic disproportion

• Placenta previa

• Abruptio placenta

• Prolapsed umbilical cord

• Macrosomia - Shoulder dystocia

Dystocia

• Abnormal progress of labor

• Contributing factorssedation, anxiety, anesthesia, unripe cervix, supine position, cephlopelvic disproportion - CPD

• Managementdepends on cause

Complications of Pregnancy

Hemorrhage – late in pregnancy

Placenta Previa

Abruptio Placentae

Placenta previa

• Placenta located over/near cervical opening

• S&S: painless bleeding in 3rd trimester, hemorrhage, fetal distress

• Risk factor: multiparity in older women

• TX: Hospitalization, bedrest, ultrasound

• Care: Do not perform vag examMonitor mother and fetusPrepare for delivery / no oxytocin

Placenta previa. Low placental implantation.

Marginal (low-lying)

Total placenta previa

Abruptio Placentae

• Premature separation of placenta• S&S: Concealed or apparent hemorrhage in

3rd trimester, uterine tenderness, abd Pain, Board like abdomen, shock, fetal distress

• Risk factors: PIH, multiparty, DM• TX: Replacement of blood loss, IV fluids,

delivery• Care: Explain procedures, monitor mother and

fetal condition, prepare for delivery

Marginal abruption with external hemorrhage.

Abruptio placentae.

Complete separation with concealed bleeding.

Abruptio placentae

Shoulder Dystocia

• Risk factorsdiabetes; macrosomic infantobesityprolonged second stageprevious shoulder dystocia

• Morbidity

• Management

Position for prolapse cord

Prolapsed Cord

• Cause – increase risk - high station,AROM, poor fit, hydramnios, breech

• Signs of prolapse – visible, suspect• Management – Emergency - Call Light

Reduce cord compressionPosition hip higher than headHold fetal part upward

Give oxygen 8-10 liters/min• Prompt delivery is the priority

Other Complications

• Precipitous delivery

• Retained placenta

• Uterine inversion

• Uterine rupture

• Umbilical cord problems

• Multiple births