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Normal Labor and Delivery

Terms in this set (166)

Physiologic Response
- Labor: The process of birth
- Delivery: The birth itself
Maternal responses that must occur in order for the delivery process to happen
- Characteristics of contractions
- Contraction Cycle
- Cervical Changes
If status of the membranes is in question
Nitrazine and fern testing may assist in the determination
Uterine contractions lead to an
Increase in maternal blood pressure
Discourage supine position during uterine contractions and encourage
Side lying tilted position
During Labor & Delivery the pt is at an
Increased risk for thrombi/blood clots
Why is the patient at an increased risk for thrombi?
- Increase in erythrocytes
- 1-2 L more blood (volume)
- Hypercoagulation (↑fibrinogen & ↓fibrinolysis)
What is the safe margine for H&H labs during labor & delivery
Hgb 11-16 g/dl
Hematocrit 33-47%
Nursing interventions to prevent thrombi include
- Ambulate pt
- SCD's after delivery
- Have pt drink lots of fluids
During labor and increased rate & depth of respirations can lead to
Hyperventilation
Signs and symptoms of hyperventilation
- Rapid respirations
- Sighing breaths
- Numbness and tingling of hands/feet
- Lightheadedness
- Loss of consciousness
Nursing interventions to prevent hyperventilation
- Have mom breath (Count to 10)
- Breath in paper bag
During Labor Gastric Motility
Decreases d/t reduced levels of progesteron

**Pt may become more thirsty/have dry mouth**
During labor decrease the pt's intake of foods and liquids d/t
Prevention of aspiration in the event that a C-Section is warrented

**moderate clear liquids diet only**
During labor and deliver the pt has a
Decreased bladder Sensation
Problem that can occur from a decreased bladder sensation include
Baby may not be able to descend d/t full bladder
After delivery a patient become
- Diuresis
- Diaphoretic
After an epidural is given a foley is placed so that
The pt's bladder can empty in order for the uterus to descend properly and contract to prevent hemorrhaging
Uterine contractions are
- Involuntary
- Coordinated (contracts and relaxes)
- Intermittent (Starts and Stops)
Pattern of contractions must increase in
- Intensity
- Frequency
- Duration
Tension caused by anxiety and pain can result in
- Slow contractions
- Increased resistance to the descent of the fetus
Interventions for decreasing anxiety
- Education
- Preparation
- Relaxation
- Breathing techniques
- Distraction
- Touches
- Focal point
- Visualization
- Support

(assists the women in completing the process of labor)
Being active and walking
Stimulates contractions
For labor & delivery to be successful pt must have
Contractions
During a contraction the baby does not recieve
Oxygen
Baby recieves oxygen when the uterus
Relaxes after a contraction
A contraction begins at the
Fundus (head) of the uterus and moves its way down the uterus
Intensity
Refers to the strength of the contraction during the acme
Interval
Refers to the time of the resting period between concentration
Intensity pattern of a contraction
- Mild
- Moderate
- Strong
Duration is the
Beginning of a contraction to the completion of the same contraction

(expressed in seconds)
Frequency of a contraction is
The time between the beginning of one contraction and the beginning of the next contraction

(expressed in minutes)
Phases of a uterine contraction
1. Increment
2. Peak
3. Decrement
4. Interval
Increment (contraction phase)
Build (increase) of intensity to the contraction
Decrement (contraction phase)
Decrease in intensity after the contraction
During the interval phase the baby get
Reprofused w/ oxygen and nutrients and excretes waste
Uterine contractions cause the cervix to
Dilation
Effacement
Cervical effacement
Progressive shortening and thinning of the cervix during labor. (0-100%)
Cervical dilation
Increase in diameter of the cervical opening measured in centimeters. (0-10 cm)
Contractions are assessed by
Palpation
Electronic fetal monitor can be used to
Obtain information about the contraction pattern using either external or internal pick up
4'p of the Birthing Process
- Powers
- Passage
- Passenger
- Psychosocial
Powers of the birthing process include
Uterine Contractions
Pushing Effort
- Primary and secondary forces needed to achieve the birth
Primary forces of labor
Uterine muscular contractions
Secondary forces of labor
Voluntary use of abdominal muscles
(used to push the fetus during the secondary stage)
Teach pt to push w/ contractions to avoid
Maternal exhaution
Pushing helps to descend
The baby
When maternal exhaution occurs use
Vaccum & Forceps
If baby's HR decels then a
C-section may be warrented
Passage of the birthing process includes the
Bony canal through which the fetus must pass

Maternal pelvis
- False pelvis
- True pelvis
False pelvis
- Supports the weight of the uterus
- Shallow basin above the inlet or brim

**If baby is in false pelvis it is still to high for delivery**
True pelvis
- Represents the bony canal through which the fetus must pass
- Consists of inlet, midpelvis and outlet

**Once baby's head is at the linea terminalis the baby is engaged and ready for delivery**
Inlet
Upper border of the true pelvis
Midpelvis
Curved canal w/ a longer posterior than anterior wall
Outlet
Lower border of true pelvis
What does Relaxin do?
Relaxes the pelvic bone to the forces of labor
Fear & Anxiety releases
Catecholamines during the labor process
Stress and fear can inhibit
Fetal blood flow and contactility
Passengers of the birthing process includes the
- Fetus
- Umbilical cord (Membranes)
- Placenta
Fetal head is the largest part of the body and therefore is the
Structure of concern
The fetal head is comprised of
- Sutures
- Bones
- Fontanelles
Bones of the head
- Fontal
- Parietal
- Temporal
- Occipital
4 sutures of the head
- Lambdoidal
- Sagittal
- Coronal
- Frontal
2 fontanelles
- Anterior
- Posterior
Fetal head can
Mold through the birth canal
Fetus has fontanels that are held together by sutures that assist in
The molding process through the birth canal
Newborn Molding
The bones are unfused and connected by flexible sutures.

This allows the fetal head to "mold" (change shape) during birth.

This is often described as a "cone head".
What part of the fetus' head do you want to see crowning through the birth canal?
Occipit
Fetal Attributes include
- Fetal lie
- Fetal attitudes
- Fetal presentation
95% of the time the fetus will enter the birth canal in the
Cephalic and longitudinal lie
Lie refers to the
Relationship between the long axis of the fetus and the long axis of the mother
Types of fetal lie
- Longitudinal
- Transverse
What type of fetal lie is necessary for delivery?
Longitudinal Lie
Longitudinal Lie
When the 2 axes are parallel
Transverse Lie
When the 2 axes are perpendicular
Fetal attitudes refer to the
Relationship of the fetal parts to one another
Types of Fetal Attitude includes
- Flexion
(Optimal attitude) this is what we want the baby to look like

- Extension
(This is what we don't want)
Presentation
Fetal part entering maternal pelvis first
Fetal Presentations includes
- Cephalic
- Breech
- Shoulder
Cephalic Presentation (head first)
- Head
- Vertex
- Military
- Brow
- Face
Vertex presentation
- Complete flexion
= Occiput presenting
Military presentation
- Neither flexed or extended
- Top of head presenting
Brow presentation
- Partial extension
- Forehead presenting
Face presentation
- Complete extension
- Face presenting
Breech Presentation (butt/feet first)
- Buttock
- Foot
- Frank
- Full
- Footling
Shoulder Presentation
Shoulder
Variations of the breech presentation
- Frank breech
- Full breech
- Single footling breech
4 quadrants of the maternal pelvis
- Left occiput anterior
- Right occiput anterior
- Left occiput posterior
- Right occiput posterior
Leopold's Maneuvers
Common and systematic way to evaluate the maternal abdomen
1st Maneuver of Leopold's
Palpate upper abdomen w/ both hands
2nd Maneuver of Leopold's
Moving hands downward, palpate both sides of the abdomen

Locate smooth side (back) and knobby side (hands and feet)
3rd Maneuver of Leopolds
Place one hand just above the synthesis and palpate for firm round structure
4th Maneuver of Leopold's
Facing the laboring women's feet, place hands on the lower abdomen, noting cephalic prominence
Ascultate through the fetal back to
Hear the heart tones best
What do fetal heart tones heard in the upper abdomen indicate
A breech presentation
Intervention for breech
Confirming the breech presentation and notifying the HCP
Fetal position
Relationship of the presenting part to the maternal pelvis
Individual & Cultural Values Assessment Should Include
- Assess patient's cultural values regarding labor and birth
- Identify primary support person
- What comfort measures are expected/acceptable?
- Are there practices/birth rituals that are culturally defined?
- Are there communication barriers?
Premonitory
Prior to labor
Premonitory Signs of Labor
- Braxton Hicks contractions
- Lightening
- Increase in clear and non irritating vaginal secretions
- "Bloody show"
- Energy spurt
- Small weight loss
- ROM
Braxton Hicks contractions
Intermittent, irregular and uncomfortable uterine contractions that occur with increasing frequency as the pregnancy progresses
Lightening
The sensation of the fetus moving from the false pelvis to the true pelvis. Occurs 2-3 weeks before the onset of labor.

**Usually mom can breath better and thus starts to nest**
"Bloody show"
Pink tinged vaginal secretion also known as a mucus plug
Energy spurt
Extra energy 24 to 48 hrs before the labor

(Nesting period)
Small weight loss
1-3lbs
True Signs of Labor
- Regular contractions increasing in intensity
- Interval gradually shortens
- Intensity increases w/ walking
- Discomfort begins in back and radiates to abdomen
- Progressive Cervix Changes

**Progesteron will regress**
False signs of labor
- Irregular contractions w/ no change in intensity or shortening of interval
- No change in dilatation or effacement
- Discomfort begins in abdomen
- Contractions not effected by walking
Cervical Changes include
- Dilation
- Effacement
- Station
Engagement
- Occurs when the largest diameter of the presenting part reaches the pelvic inlet
- Can occur several weeks before the process of labor begins
- Can be determined by vaginal exam
Station
Refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis

Fetus movement from false pelvis(Anything above the the ischial spine -3 to 0) passed designated zero station to movement of (anything below the ischial spine 0 to +3)
Cervical effacement
The progressive shortening and thinning of the cervix during labor (Expressed 0-100%)
Cervical Dilatation
The increase in diameter of the cervical opening measured in cm (0-10cm)
Pt can push when they are at
100% of effacement
Semen can cause the
Cervix to undergo changes and induce true labor
Sterile Vaginal Exam (SVE)
The nurse, midwife, HCP assess labor progress by doing an SVE

*Examination is subjective*
Disadvatages of a Sterile Vaginal Exam (SVE)
Risk for infection
Sterile Vaginal Exam (SVE) Findings include
- cm dilation
- % effacement
- StationStatus of membranes

Documentation Example: 4cm/80%/-1

*True labor if progression occurs in these findings*
Stages of Labor
•First stage
- Latent phase 3-5 cm
- Active phase 4-6 cm
- Transition phase 7-10 cm
•Second stage (pushing and ends with birth)
•Third stage (ends with delivery of placenta)
•Fourth stage (recovery of 1-4 hours after delivery of the placenta)
First stage of labor
Begins w/ the onset of labor and ends when the cervix is completely dilated to 10cm
During the latent phase the pt is
- Talkative
- Excited
- Asking questions
Characteristics of the latent phase of labor
- Frequency q5-30min
- Lasting 30-40 seconds
- Mild intensity
Nursing assessments of the latent phase of labor should include
- Vital signs
- FHT
- Contraction pattern
- Knowledge and plans
Nursing intervention during the latent phase of labor
- Diversion
- Support
- Information
During the active phase the pt is
- Anxious
- Focused
- Sense of helplessness
Characteristics of the active phase of labor
- Frequency q2-5 mins
- Lasting 40-60 seconds
- Moderate intensity
Nursing assessments of the active phase of labor should include
- Vital signs
- FHT
- Contraction pattern
- Bladder
- Cervical changes
- Station
- Pain
Nursing intervention during the active phase of labor
- Pharm pain relief
- Assist w/ relaxation and breathing
- Encouragement and support
- Position change
During the transition phase the pt is
- Restless
- Irritable
- Frustrated
- Hiccuping
- N/V
- Legs shaking
- Withdrawn
Characteristics of the transition phase of labor
- Frequency q1 1/2- 2 mins
- Lasting 60-90 seconds
- Strong intensity
Nursing assessments of the transition phase of labor should include
- Vital signs
- FHT
- Contraction patterns
- Cervical dilatation
- Station
- Pain
- Coping abilities
Nursing intervention during the transition phase of labor
- Presence of nurse
- Reassurance
- Assistance w/ breathing
- Assistance w/ N/V & leg shakes
- Acceptance of irritability
- Instruction on how to avoid pushing
Second stage of labor
Starts w/ 10cm dilation and ends with birth
Signs of the 2nd stage of labor
- Complete dilatation of cervix
- Urge to bear down
- Increase in bloody show
- Rectal pressure
- Bulging perineum
Third stage of labor
Starts w/ birth of baby and ends with delivery of placenta (20-30 mins)
Signs of the 3rd stage of labor
- Globular shaped uterus
- Rise of the fundus in the abdomen
- Sudden gush or trickle of blood
- Further protrusion of umbilical cord out of the vagina
Fourth stage of labor
- Recovery of 1-4 hours after delivery of the placenta
(First 1-2hrs in L&D and then 2-4hrs in postpartum)
When should the pt go the hospital?
- Uterine Contractions
- Rupture of membranes
- Red Bleeding
- Decreased Fetal Movement
- Other concerns
Nursing Responsibilities During the Admissions Process of the Pt to L&D
- Build therapeutic relationship
- Assessment of maternal/fetal
- Interview pt
Assessment of maternal/fetal
- First priority is to put mom on monitor
- Assess contractions and fetal heart rate (FHR)
- Assess uterine activity
When interviewing the pt ask if
- Bottle or breastfed
- Who is support person
What is the biggest indicator that the baby is fine?
- Fetal Heart Rate
- Amniotic fluid
Amniotic Fluid Status is Determined by
•Intact
•Ruptured
-Spontaneous ruptured membranes (SROM)
-Artificial rupture of membranes (AROM)
•Color
-Clear
-Yellow
-Meconium
•Amount
What does meconium in the amniotic fluid mean?
Fetal distress
Maternal Assessments on Admissions
- Vital signs
- Physical exam
- Cervical exam
- Contraction patterns
- Membrane status
- Fetal status
- Cultural assessment
- Labor Progress determined via (SVE)
- I&O
- Preparation
- Emotional response to Labor
- Support available
Procedures performed on admission
- IV start
- Blood labs
- Urine dipstick
- EFM placement
Maternal Assessments after Admissions
- VS
- Contractions
- Labor Progress (SVE)
- I&O
- Response to Labor (also Support Person's Response)
Assessing for intrapartal high risk factors is an
Integral part of assessing the laboring women
Nursing Care During Labor Includes
- Observing for "conditions associated with fetal compromise"
- Promote placental function
- Provide comfort measures
- Teaching
- Labor support
Nursing Care During Delivery Includes
- Delivery set-up
- Delivery Personnel
- Positioning
- Observe Perineum
Nursing Care After Birth for the Infant
- Support cardiopulmonary function
- Support thermoregulation
- Identification
- Assign APGAR score
- Skin to skin bonding
- 2 bands on the baby
APGAR score
- A method for evaluation of the infant cardiorespiratory adaptation after birth.
- The nurse scores the infant at 1 and 5 minutes after birth in each of five areas.
- The assessments are arranged from most important (heart rate) to least important (color)
- The infant is assigned of score of 0 to 2 in each of the five areas and the scores are totaled.
Nursing Care After Birth for the Mother
- Observe for hemorrhage
- Relieve discomfort
- Promote family attachment
The causes of labor onset is
- Unknown but there are several theories
- Progesterone withdrawal hypothesis
- Prostaglandin hypothesis
- Corticotropin-Releasing Hormone
Primigravida
16-18hrs
Multigravida
8-10hrs
Factors that may influence a womans response to pain are
- Culture
- Fatigue
- Sleep deprivation
- Anxiety
- Previous experience
- Support
- Preparation
Goal of pain management
Provide max pain relief at the min risk for the mother and fetus
Methods of non pharm pain relief
- Touch
- Relaxation
- Breathing pattern
- General comfort
- Ambulation
- Frequent position change
- Empty bladder
- Diversion
- Visualization
Criteria needed before the administration of systemic analgesia
- Maternal stable VS
- No contraindications to drugs
- Reassuring FHT pattern
- Fetal variability present
- Term gestation
- Contraction pattern est.
- Cervical dilatation
- Progressive descent of the presenting part
Most common drugs used for pain relief
- Stadol
- Nubain
Stadol and nubain can cause
Respiratory depression
Epidural Block
Injection of an anesthetic agent into the epidural space
Spinal Block
Injection of an anesthetic agent into the spinal fluid
Side effects of Epidural and Spinal block
- Hypotension
- Inability to void
- Inability to push during 2nd stage
- Pruritus
- Interventions
Precaution of epidural and spinal block
- Bolus of 500cc to 1000cc of IV fluid
- Lab work
- VS
- FHT
- Bladder assessment
General anesthesia is used for
- C/S and surgical interventions
- Used primarily in emergency situations
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