Unit 2 OB Intrapartum LABOR & DELIVERY Rev. 2013
Unit 2 OB Intrapartum
LABOR & DELIVERY
Rev. 2013
Signs of Impending Labor
1. Lightening
2. Bloody Show
3. Braxton Hicks Contractions
4. Energy Spurt
5. Weight Loss
True vs. False Labor
• Regular pattern
• Inc. in duration frequency & intensity
• Inc w/ ambulating
• Rarely follow a pattern
• Vary in duration, frequency and intensity
• Dec w/ ambulating
True vs. False Labor
• Start in back & radiate to abd.
• Dilate & efface cervix
• “show” usually is present
• Often noticed in abdomen
• No cervical changes
• “show” not present
2 Common signs of Active Labor
• 1. Strong, Regular Contractions
• 2. R.O.M.
Monitoring Fetal StatusUterine Contractions
• Involuntary
• Can be felt at uterine fundus
• Documented according to frequency, duration and intensity
Rupture of membranes
• B.O.W. Bag of Waters
• 1000cc or 1 qt. By 40th week
• Prior to delivery sac must break
• Amniotomy (SROM or AROM)
4 Stages of Labor
1. Dilation
* begins w/ onset of true labor
*ends w/ complete dilation of cervix
Primip ~ 10-12 hrs Multip 6-8 hrs
First Stage of Labor
• Has 3 distinct phases:
1. Latent excited
2. Active apprehensive
3. Transitional irritable & frustrated
2 distinct cervical changes
1. Dilation Cervical os begins to open Meas. In cm from 1-10 Complete dilation nec. to expel fetus Solely the result of contractions
2. EffacementRefers to thinning & shortening of
cervixNormally long & thickNow shortens or thinsMeas. in % (100%=complete)
2. Delivery or Expulsion
• Begins w/ complete dilation of cervix & ends w/ birth of newborn
Primip ~ 30 mins.- 2 hrs
Multip ~ 20 mins.- 1.5 hrs.
3. Placental
Begins w/ delivery of newborn & ends w/ delivery of placenta
(usually 5-20 mins.) for both primiparas and multiparas
4. Recovery/Stabilization
begins after delivery of placenta & ends w/ pt. being in stable condition
most crucial time for hemorrhage
(~ 2-4 hrs. After delivery)
Station,Lie,Position & Presentation
1. Station Means level of descent of fetal
presenting part in birth canal Measured in relation to the level of
ischial spines Vertex is most common presentation
At station 0, fetal head is engaged
Other stations are 1-3 cm above (-) or below (+) station 0
2. LieDenotes the position of the
fetal spinal cord (long part) to that of the woman
Normal lie is longitudinalTranverse lie cannot be
delivered
3. Position
refers to the relationship of the presenting fetal part to a quadrant of the maternal pelvis
Most favorable position is LOA
4. Presentation
• Refers to part of fetus that first enters birth canal
• 96% are cephalic or vertex presentation
• Other presentations are breech, face, shoulder
Breech Birth• Notice the foot
6
• It’ a boy
it's
• The body is almost out
Finally
Admission Assessment
Review Box 26-5 Pg. 828
CRITICAL THINKING QUESTION
•What are the 3 most important elements of your Admission Assessment?
Elimination/Activity/Exercise
• Keep bladder empty
• L side lying
• Breathing exercises
Relief of Discomfort
a. Epidural blockb. Saddle blockc. Caudal blockd. Pudental blocke. Paracervical or Cervical block
Fetal Monitoring
• Purpose:
- is to record fetal H.R. with
contractions & relaxation
- is to detect early warning
signs of fetal distress
Monitoring may be:
• External ( Indirect )
• Internal ( Direct )
Evaluation of Monitor Information
• Accelerations Transient inc. of the FHR of 15
BPM or more.Accelerations of 60 BPM or
more is considered a complication
Decelerations
Are slowing of the FHRAre a normal response of the
fetus to labor & should mirror the pattern of contraction.
Caused by head compression
Normal Variability
• Change in FHR from beat to beat
• Normal range is 2-10 beats/min
Decreased Variability
-Little or no fluctuation in FHR
May indicate fetal nervous system abnormality OR
Maternal use of CNS depressants
Signs of Fetal Distress
• Increase or decrease in baseline FHR
• Decrease in baseline variability
• Tachycardia
• bradycardia
Out to the neck
• Persistent late decelerations
• Severe variable decelerations
• Greenish-stained amniotic fluid
• Prolapsed cord
During the 2nd Stage of Labor:
Bearing down feelingRectum dilates, perineum
bulgesCrowning occursPerineal prep
Prepare for Delivery CoachingEpisiotomy done to prevent laceration
or tearingLacerations
Delivery of Newborn
1. Nose & mouth are suctioned
2. Check for nuchal cord
3. Note time of delivery
Response & Care of the Newborn to Birth
Establish & maintain airwayStimulate respirationsPosition to prevent aspirationProvide warmth Determine APGAR ScoreAssess cord for bleeding
Identification
Health Record
EES or Tetracycline to eyes
Vitamin K injection
Bonding
Third Stage of Labor
Extends from the time the newborn is delivered until the placenta & membranes are expelled
Can last up to 30 min., usually takes 5-20 min.
Delivery of Placenta
1. Shiney Schultze Dirty DuncanPlacental examinationOxytocin
Nursing Care during 3rd Stage
Massage fundus Cleanse perineum Remove legs from stirrups Change gown, apply peripad Provide warmth
Fourth Stage of Labor
• Involution begins
• 6 week process
Nursing Care during 4th Stage
1. Assess VS – q 15 min x 1-2 hours
2. Check fundus
3. Check perineum
4. Check lochia
5. Check for 1st void
6. Check for signs of hemorrhage
6. Patient Education Teach….
perineal careFundal massageFluid intake/voidingBreastsconstipation
after painsNursing/breast feeding
Complications of Labor & Delivery
A. Premature Rupture of Membranes
• Small leak in BOW causing a rupture of membranes
• May be difficult to diagnose
• Complications are: Premature labor,Intrauterine infection & malpresentations, prolapsed cord
Treatment
• Hospitalization
• Assessment of woman & fetus
• Determine fetal maturity
• Induce labor if fetus is mature
B. Premature Labor
• Labor that occurs before the 37th week
• Prematurity leading cause of infant mortality
• Tx is Bedrest, Tocolytic drugs
C. Precipitate L & D
Labor is brief < 3 hoursContractions unusually
severeMay be so rapid getting to
delivery room is impossible
Nursing Care
• Never prevent delivery
• Assist with birth
• Make sure neonate is breathing
D. Uterine Rupture
• One of the most serious complications – very rare
• Predisposing factors/causes
1. previous C/S or uterine scar
2. severe tonic contractions
3. Dystocia
4. Injudicious use of oxytocic drugs
5. CPD (Cephalopelvic Disproportion)
E. Dystocia
• Prolonged, difficult & painful labor
• Does not result in dilation or effacement
• Exhausts woman & predisposes to death
Causes of Dystocia
1. Uterine inertia
2. CPD
3. Abnormal fetal positions or presentations
Management for Abnormal Positions & Presentations….
1. Version (Leopold’s Maneuvers)
2. Forceps assisted delivery
3. Vacuum assisted delivery
4. C/S
F. Cord Problems
A. Prolapsed Cord umbilical precedes the baby Serious complication May cut off fetal circulation Requires emer. C/S
Nuchal Cord
• Cord wrapped around neck
• If discovered before labor,
C/S is done
*If not, forceps are used to speed delivery & cord cut immediately
Other Considerations of Labor & Delivery
The Induction Process• Drugs may be administered
parenterally, orally, or vaginally• Oxytocin most common• (PGE) Prostaglandin E
(Cervidil)• Amniotomy
Nursing Care during Induction
1. Note the time of amniotomy, color & amount of fluid
2. Monitor fetus for signs of distress
3. VS q 10-15 min. then q 30 min. fol. Rupture of membranes
Emergency DeliveryNever to be delayedRemain calm & deliver babyFollow aseptic techniqueDouble tie cord Keep baby warm, ensure
breathing
Cesarean Delivery
Post Op
Care
• Assess VS
• Observe lochia, incision & fundus
• I & O for 24-48 hrs
• Advance diet as tolerated
• Perineal care
• Early ambulation & breathing exercises
CRITICAL THINKING QUESTION
• A patient is in her third trimester and informs the nurse during her prenatal visit that she is experiencing constipation and stress incontinence. The patient asks the nurse how she can manage these problems. What information should the nurse provide for this patient?