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Passageway, Passanger, Powers, Position, Pyschological/Psychosocial Responses

5 P's of Labor

Gynecoid

Favorable for vaginal delivery of newborn

Android

Not favorable for vaginal delivery of newborn
Hint (A)

Anthropoid

2nd Favorable for vaginal delivery of newborn

Platypelloid

Not favorable for vaginal delivery of newborn
Hint (P)

Station

Relationship of the presenting fetal part to an imaginary line drawn between the pelvic ischial spines -5 to +5, -3 to +3

Engagement

Ballottement, Dipping, Engagement

Ballottement or Floating

Fetal head is directed down toward the pelvis but can easily move away from the inlet

Dipping

Fetal head dips into the inlet but can be moved away by exerting pressure on the fetus

Engaged

Biparietal diameter (BPD) of the fetal head is in the inlet of the pelvis

Cervix

Dilatation, Effacement occurs here

Effacement

Thinning and shortening of the cervix that occurs late in pregnancy or during labor

Vertex Presentation

Most common presentation, fetal head is completely flexed onto the chest, and the smallest diameter of the fetal head (suboccipitobregmatic) presents to the maternal pelvis. The occiput is the presenting part.

Military presentation

Fetal head is neither flexed nor extended. The occipitofrontal diameter presents to the maternal pelvis (occipitofrontal diameter) is the presenting part.

Brow presentation

Fetal head is partially extended. The occipitomental diameter, the largest anteroposterior diameter, is presented to the maternal pelvis (submentobregmaticdiameter); the sinciput is the presenting part

Face presentation

Fetal head is hyperextended. The submentobregmatic diameter presents to the maternal pelvis (Occipitoental diameter); the face is the presenting part.

Complete Breech

Fetal knees and hips are both flexed, thighs on the abdomen, and the calves are on the posterior aspect of the thighs. The buttocks on feet of the fetus present to the maternal pelvis.

Frank Breech

Fetal hips are flexed, the knees are extended. The buttocks of the fetus present to the maternal pelvis.

Footing Breech

Fetal hips and legs are extended, and the feet of the fetus present to the maternal pelvis. In a single footing 1 foot presents, in a double footing 2 feet present

Transverse Lie

A shoulder presenting part, and the acromion process of the scapula is the landmark to be noted; but could be fetal arm, back, abdomen, or side may present

Fetal Lie

Relationship of cephalocausal axis of fetus to cephalocaudal axis of woman

Primary forces of Labor

Uterine Muscle Contractions
Frequency, duration, intensity
Contraction Phases: (Increment, Acme, Decrement, Resting Period)

Secondary force of Labor

Use of Uterine and abdominal muscles to push during second stage of labor
cervical changes, dilatation, effacement

Frequency

Time between the beginning of one contraction and the beginning of the next contraction

Duration

Measured from the beginning of a contraction to the completion of that same contracction

Intensity

Strength of the contraction during acme

Progesterone

Causes relaxation of smooth muscle tissue
(previous--the pregnancy hormone)

Estrogen

Causes stimulation of the uterine muscle contractions

Connective Tissue

Loosens and permits softening, thinning, opening of cervix

Muscles of the upper uterine segment

Shorten and cause the cervix to thin and flatten

Maternal positions during labor

Ambulation, Squatting, Side positioning

Psychosocial responses to labor

Understand & prepare for childbirth, Fantasies, Amount of support from others, Present emotional status (fears--losing control), Beliefs/values, If more relaxes, quicker labor

Possible cause for onset of Labor

↓ Progesterone, ↑ Estrogen, Prostaglandins, Oxytocin, Corticotrpoin-releasing hormone
Weakened cervix (collagen fibers break down)
Fetus--- ↑ cortisol levels

Impending labor

Weight loss (1-3 lbs), N/V/D, indigestion, Observe changes in sensations (Restal pressure, ↑ leg cramps, ↓ SOB, Braxton Hicks contractions, Rupture of membranes, Lightening, Dilatation, Bloody Show, Sudden burst of energy

True labor

Contractions at regular intervals--increase in duration/intensity
Discomfort begins in back and radiates to front of abdomen
Walking intensifies contractions
Resting or relaxing in wam water does not ↓ intensity
Contractions produce cervical dilatation

False labor

Irregular contractions that do not ↑ in duration or intensity
Contractions are lessended by walking, resting, or warm water
Discomfors felt primarily in abdomen
Contractions produce no effect on Cervix
Drink large amounts of water

1st stage, latent, physiologic

Regular mild contractions begin
Frequency 5-7 minutes, duration 30-40 seconds
Cervical effeactment and dilation begins 0-3 cm

1st stage, latent, psychological

Relief that labor has begun
High excitement w/some anxiety

1st stage, active, physiologic

Contractions ↑ in intensity to moderate
Frequency 2-3 minutes, duration 60 seconds
Cervical dilation ↑ from 4-7 cm
Fetus begins to descend into the pelvis

1st stage, active, psychological

Fear of lossing control
Anxiety ↑

1st stage, transition, physiologic

Contractions continue to ↑ in intensity
Frequency 1 1/2 ti 2 minutes, duration 60-90 seconds
Cervix dilates from 8 to 10 cm
Fetus descends rapidly into the birth passage
May experience reactal pressure, N/V

1st stage, transition, psychological

↑ feelings of anxiety, irritability
Eager to complete birth experience
Need to have support person or nurse at bedside

Cardiovascular changes during labor

Cardiovascular changes: Cardiac output
B/P ↑ w/contraction, ↑ w/pushing
: : Gatrointestinal

Respiratory changes during labor

↑ oxygen demand/consumption, mild respiratory acidosis usually occurs by the time of birth

Renal system changes during labor

↑ in renin, plasma renin activity, angiotensinogen
Edema may occur at base of bladder due to pressure of fetal head

Gastrointestinal changes during labor

Gastric motility ↓
Gastric emptying is prolonged
Gastric volume remains ↑

Immune System?other blood values

WBC ↑ 4500- 20,000
Blood glucose ↓

2nd stage, labor, physiologic changes

Begins w/complete dilation and ends w/birth of infant
Pushes due to pressure of fetal head on sacral and obturator nerves
Uses intra-abdominal pressure
Perineum begins to bulge, flatten and move anteriorly as fetus descends

2nd stage, labor, psychological changes

May feel a sense of purpose
May feel out of control, frieghtened, and irritable

Episiotomy

Surgical incicion of perineal body to enlarge outlet
commonly used to avoid spontaneous laceration
Usually performed w/regional or local anesthesia

Fetal Responses to Labor

labor may cause no adverse effects in healthy fetus
Fetal HR may ↓ as head pushes against cervis
Blood flow ↓ to fetus at peak of each contraction leading to ↓ in pH
Further ↓ in pH occurs during pushing due to woman holding her breath

3rd stage, labor, physiologic

Placental separation, uterus contracts and placenta begins to separate
Placental delivery: bears down and delivers placenta--physician may put slight traction on cord to assist delivery of placenta

Placenta delivery, classic signs

Rounding up of uterus, upward movement of uterus, lengthening of umbilical cord, gush of blood from vagina

3rd stage, labor, psychological

Woman may feel relief at completion of birth
Woman usually focused on welfare of infant and may not recognize that placental expulsion is occurring

4th stage, labor, physiologic

1-4 hours--check V/S, Output, uterine contractions (involution)
↑ pulse, ↓ BP due to redistribution of blood from uterus and blood loss
Uterus remains contracted/located between umbilicus/symphysis pubis
May experience a shaking chill
Urine may be retained due to ↓ baldder tone and possible trauma to the bladder

4th stage, labor, psychological

May experience euphoria/energized at birth of child
May be thirsty and hungry

1 stage, Pain

Arises from dilation of cervix, stretching of lower uterine segment, pressure, and hypoxia of uterine muscle cells during contractions

2nd stage, Pain

Arises from hypoxia of contracting uterine muscle cells, distention of vagina and perineum, and pressure

3rd stage, Pain

Arises from contractions and dilation of cervix as placenta is expelled

Pain Medications--IV

nalbuphine (Nubain)
butorphanol (Stadol)
promethazine (Phenergan)--enhances effectiveness of pain meds and for nausea

Epidural check list

Check for low platelet count, spinal deformities or spinal surgeries
Injection of anesthertic agent into epidural space
Produces little or no feeling to area from uterus downward
Hytotension is most common S/E

Epidural Nursing Care

VS q2 min thru medication bolus, q 5 min for 30 minutes, q 15 minutes until removed
FHR q 15 minutes
Have a crash cart available
May preload w/crystalloid solution bolus
Pushing during 2nd stage of labor maybe impaired due to lack of sensation
May need urinary catheterization due to loss of bladder sensation
Assess sensation motor control/orthostatic BP, T elevation

Spinal Block

Local anesthetic agent injected directly into spinal canal
Leval of anesthesia dependent upon level of administration ---onset of anesthesia is immediate

Spinal Block--S/E

Severe HA
Maternal hypotension, which can lead to fetal hypoxia requiring frequent BP monitoring health changes
Indwelling urinary catheter usually needed due to ↓ bladder sensation/tone
Woman's legs must be protected from injury for 8 to 12 hours due to ↓ movements/sensations

Pudendal Block

Local anesthesia injected directly into pudendal nerve, which produces anesthesia to lower vagina, vulva, perineum
Only produces pain relief at end of labor
Has no effect on fetus or progress of labor
May cause hematoma, perforation of rectum, trauma to sciatic nerve

Loacal Infiltration

Local anesthesia injected into perineum prior to episiotomy
Provideds pain relief only for episiotomy incision
No effect on maternal/fetal VS
Requires large amts of local anesthetic agents

Admission Nursing Care

Provide orientation to the unit and obtaining overall physical assessment of mother--Determine imminence of delivery, crowning, rectal pressure, grunting, ↑ bloody show, Assess maternal VS/FHR, Perform vaginal exam to determine stage of cervical dilatation/membranes--time, amt, color, odor, -- do not complete vaginal exam if bleeding, Nitrazine paper turns blue/green if ROM, determine frequency and intensity of contractions

Medical History

Maternal history and note presence of any high risk factors

Personal Data

Age, Due Date, Weight
Medical problems or pregnancy complications
Blood type and Rh factor
Results of seroligical testing, Group B strep
Allergies to medications, food, and other subs
Note prescribed, OTC meds taken during pregnancy, and hx of sub abuse, use of alcohol and tobacco
Last time ate or drank

Nursing Care--Cultural

Address and honor values and beliefs of laboring woman
Nurses more effective when aware of---cultural beliefs of specific group

Nursing Responsibilities

Have client sign consent forms
Start IV--18 ga catheter, Lactated Ringer's
Obtain labs---CBC, RPR, Blood Type, U/A
Complete Head to Toe Physical Assessment

Lab Assessment

Evaluate complete CBC for signs of infection, blood dyscrasia, or coagulation problems
--Evaluate WBC, HGB, for ↓ in Oxygen carrying capacity, Platelet count
Evaluate results of serologic testing
Assess for Rh negative woman
Assess, urine for glucose, ketones, protein--evaluate for possible UTI and instruct the woman in collection techniques

Psychosocial Assessment--admission

Laboring client has previous ideas, knowledge, and fears about childbearing--using assessment techniques, nurse can meet laboring client's needs

Psychosocial Assessment--Anxiety

Observe for rapid breathing, nervous tremors, frowning, grimacing, clenching of teeth, thrashing, crying, and ↑ pulse & respirations---teach relaxation, breathig, breathe into paper bag if hyperventilating

Support Assessment

Father or support person
What are thrir caretaking activities, such as soothing conversation and touching
Does relationship involve interactions? Is support person in close proximity?

Domestic Violence Assessment

Has anyone close to you ever threatened to harm you?
Have you ever been hit, kicked, slapped or choked. If yes, by whom? What is the total number of times?
Has anyone, including your partner, ever forced you to have sex?
Are you afraid of your partner or anyone else?

Nursing Interventions--Labor

Determine imminence of delivery, VS
Vaginal Discharge, Vaginal Exam
Fetal Monitoring, Hydration--IV Fluids
Elimination, When to notify MD, Midwife

Uterine Contractions

Assessed by palpation or continuous electronic monitoring
Assess at least 4 successive contractions

Assess Contractions

For frequency--noting time from beginning of one contraction to beginning of next contraction
Note time when tensing of fundus is first felt and again as relaxation occurs
Intensity of contraction can be evaluated by estimating indentabiility of fundus
Good time to assess laboring mother's perception of pain

Leopold's Maneuver Preparation

Empty client's bladder, lie on back w/feet on bed, knees bent

Leopold's Maneuver Purpose

Assist in determining fetal position, presentation, and lie

Abdominal Palpation

Facing client, palpate abdomen gently and deeply using palms of hands

External Contraction Monitor

Device placed against maternal abdomen, positioned against fundus, held in place w/belt
Device has flexible disk that responds to pressure
When fundus contacts pressure applied<"toco" and contraction displayed as pattern on monitor
External monitoring does not accurately record intensity of uterine contraction
May be difficult to obain fetal heart rate (hydramnious w/very active fetus
Belt will require frequent readjustment

Electronic fetal monitoring

Provides continuous data and is routine for high-risk clients
---Also used for women experienceing an induction of labor
---May be done externally or w/an internal monitor
Fetal heart rate heard most clearly at fetal back
---Useful to perform Leopold's maneuvers first to locate fetal HR, will help determine if multiple fetuses
When fetal HR is located, count for 30 seconds and multiply by two
---Check client's pulse against fetal sounds

Normal Fetal Heart Rate

110 to 160 BPM --rate below 110 bpm is termed bradycardia
Sustained rate of 161 or above is tachycardia
If rate is 180 bpm or above, is marked tachycardia

Variability

Variations in fetal HR, minimal moderate, marked

Accelerations

Transient ↑ in fetal HR normally caused by fetal movement--usually accompany uterine contractions due to fetal movement occurring in response to contractions

Decelerations

Periodic decreases in fetal HR from baseline---can be early, late, and variable according to time of occurrence in contraction cycle

Early Decelerations

Occur before the onset of uterine contraction, uniform in shape, benign, and ususally does not require intervention; usually related to fetal head compression leading to vaginal stimulation

Late Decelerations

Begin at peak of contraction and occur after contraction--means uteroplacental insufficiency

Variable Decelerations

Occur at any time, means umbilibal cord compression

Nursing Care, Nonreassuring FHR

Optimize maternal position, monitor maternal VS for hypotension and treat, administer IV fluids as needed,
Give supplemental oxygen if indicated, Consider discontinuing Oxytocin, Initiate contrinuous monitoring

Nursing Care Assess--Nonreassuring FHR

Perform vaginal exam to assess for prolapsed cord or labor progress
Have physician place internal monitors as appropriate
--Fetat scalp electrodes, Intrauterine Pressure Catheter within uterus in resting state and with each contraction
Assist physician w/fetal blood sampling
Prepare for expeditious birth
Provide client and family w/explanation
Administer tocolytic (terbutaline) as ordered

Labor Induction

Deliberate starting of contractions before they begin on their own
Stripping membranes, Cervidil insertion, indwelling cathetr to cervix, oxytocin infusion, amniotomy nipple stimulation

Labor Augmentation

Stimulation of labor which has begun spontaneously
Oxytocin infusion, amniotomy

Nursing Intervention 2nd Stage Labor

Notify MD or midwife, Remain w/client,
Assess maternal pulse, Respirations, BP q 5-15 minutes
Assess FHR q 5-15 minutes, Set up delivery rooms
Assist client w/breathing/pushing
Cleanse perineum
Prep for C-S if indicated

Nursing Intervention 3rd Stage Labor

Administer oxytocin as ordered, Assist MD as needed
Take care of newborn, Monitor for firmness, Assess amt of lochia

Nursing Intervention 4th Stage Labor

Assess q 15 minutes until stable for 1 to 4 hours
Maternal VS -- temperature maybe elevated due to dehydration, if pulse ↑ & BP ↓ monitor bleeding status
Lochia--measure amount (light to moderate), color (rubra), presence of clots

Nursing Intervention 4th Stage Labor

Uterus--assess firmness/location--firm @ midline, Maybe 1-2 fingers below uterus, atony--inability to contract after delivery--PP hemorrhage

Nursing Intervention 4th Stage Labor

Perineum---episiotomy/lacerations--apply ice
Bladder---monitor for distention
Pain---administer meds

C-Section Delivery

Have consent signed, Prep abdomen
Maternal VS, NPO
Patent IV, Inser indwelling urinary catheter
Obtain FHR and external monitor strip

Nursing Care General Anesthesia

Assess when mother ate or drank last
Administer prescibed premedication such as antacid
Place wedge under mother's right hip to diplace uterus/prevent vena cava compression

Nursing Care General Anesthesia

Provide oxygen prior to start of surgery
Ensure IV access is established
Assist anesthesiologist by applying cricoid pressure during placement of endotracheal tube

Complications of General Anesthesia

Fetal Depression---If mother receives general anesthesia, infant may have respiratory depression
Method not advocated when infant is considered high risk
Uterine relaxation: Most general anesthetic agents cause some uterine relaxation
Vomiting, Aspiration--agents may also cause vomiting and aspiration

C-Section Recovery

VS q 5 minutes until stable, then q 15 minutes for 1 hr, q 30 minutes until discharged to PP
Assess uterine fundus, peri pad and abdominal dressing q 15 minutes for 1 hr
Assess level of anesthesia q 15 minutes
Administer IV oxytocin
Transfer client to PP when stable

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