Transcript Labor and Delivery

Labor and Delivery
Marianne F. Moore
Critical Factors in Labor
Passage
Critical Factors in Labor
Passage
Passenger
Critical Factors in Labor
Passage
Passenger
Powers
Critical Factors in Labor
Passage
Passenger
Powers
Psyche
Critical Factors in Labor
Passage
Passenger
Powers
Psyche
Position (Maternal)
Critical Factors in Labor
Passage
Passenger
Powers
Psyche
Position (Maternal)
Placental
Passage
Skeletal Structures
Pelvis Types
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Gynecoid
Anthropoid
Android
Platypelloid
Passage
Skeletal Structures
Pelvis Types
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Gynecoid
Anthropoid
Android
Platypelloid
Passage
Soft Tissue Structures
Cervix
 Cervical Scarring
Vagina
 Obstructions
 “Tissue Dysplasia”
Passenger
Lie
Passenger
Lie
Attitude
Passenger
Lie
Attitude
Presentation
Passenger
Lie
Attitude
Presentation
Position
Passenger
Lie
Attitude
Presentation
Position
Station
Powers
Contractions
Duration
Frequency
Intensity
Powers
Contractions
Increment
Acme
Decrement
Psyche
Immediate Issues
Fatigue
Anxiety
Trust in Medical Care
and Self
Ability to Receive and
Use Support
Psyche
Pre-Existing Issues
Motivation for the
Pregnancy
Self-Confidence
Personal Expectations
Relationship with Support
Person(s)
Culture and Its’ View of
Childbirth
Obstetric/ Family History
Childbirth Education
Classes
Maternal Position
Bedrest: Low semi-Fowler’s
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Necessary position with epidural placement
Patient is tipped to one side to avoid vena cava
syndrome
Changing position from one side to other changes
relationship of presenting part to maternal pelvis
Maternal Position
Bedrest: Side-lying or “runner’s position”
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Useful for rest in early labor
Also a good position for sleep in advancing
pregnancy
Needs lots of pillows for comfort and correct
positioning
Maternal Position
Upright Positions:
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Chair/Rocker
Walking
Stair Climbing (especially 2 at a time)
Birthing Ball
Squatting/Squat Bar
Toilet sitting
Maternal Position
Positions to help back labor:
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Leaning over the bed
All fours
Pelvic rocking
Leaning on the hallway bars
Slow dancing
Counterpressure
Placenta
Low-lying placenta may cause
the baby to assume a
transverse lie
May also impede descent of
the baby
Cardinal Movements
Engagement
Cardinal Movements
Engagement
Descent
Cardinal Movements
Engagement
Descent
Flexion
Cardinal Movements
Engagement
Descent
Flexion
Internal Rotation
Cardinal Movements
Engagement
Descent
Flexion
Internal Rotation
Extension
Cardinal Movements
Engagement
Descent
Flexion
Internal Rotation
Extension
Restitution
Cardinal Movements
Engagement
Descent
Flexion
Internal Rotation
Extension
Restitution
External Rotation
Cardinal Movements
Engagement
Descent
Flexion
Internal Rotation
Extension
Restitution
External Rotation
Expulsion (BIRTH!)
Signs of Labor
Lightening
Frequent Urination
Sciatic Nerve Discomfort
Back Discomfort
Signs of Labor
Lightening
Frequent Urination
Sciatic Nerve Discomfort
Back Discomfort
Braxton-Hicks (Warm-Up) Contractions
Vaginal Discharge
Bloody show
Nesting
Signs of Labor
Rupture of membranes
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Called PROM if before contractions start
Amount of fluid can vary
Assess
Time of Rupture
Color of fluid
Clarity of fluid
Fetal movement since rupture?
Have contractions started?
Signs of Labor
What is “False Labor”?
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Looks/feels like labor to mother but no change
in cervix
Abdominal/groin pain
Changing level or type of activity makes
contractions go away
Contractions don’t get stronger, longer or
closer together (intensity, duration, frequency)
Contractions do not change the dilatation or
effacement of cervix
Signs of Labor
What is “True Labor”?
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Contractions that efface or dilate the cervix
Contractions usually cause low back pain or
suprapubic pressure (or both)
Contractions are regular and rhythmic
Changing type or level of activity does NOT
make them go away
Contractions get longer, stronger, closer
together (duration, intensity, frequency)
Theories About the Onset
of Labor
Progesterone Deprivation Theory
Oxytocin Theory
Fetal Endocrine Control Theory
Prostaglandin Theory
Physiologic changes
with L & D
Labor is hard physical work
Physiologic changes
with L & D
Labor is hard physical work
Increases in systolic and diastolic
BP
Physiologic changes
with L & D
Labor is hard physical work
Increases in systolic and diastolic BP
Increased cardiac output
Physiologic changes
with L & D
Labor is hard physical work
Increases in systolic and diastolic BP
Increased cardiac output
Fluid and electrolyte loss:
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diaphoresis
hyperventilation
elevated temperature
Physiologic changes
with L & D
Peristalsis slows in most of GI
tract, except lower colon
Physiologic changes
with L & D
Peristalsis slows in most of GI tract,
except lower colon
Decreased absorption of solids
Physiologic changes
with L & D
Peristalsis slows in most of GI tract,
except lower colon
Decreased absorption of solids
Anorexia is common
Physiologic changes
with L & D
Peristalsis slows in most of GI tract,
except lower colon
Decreased absorption of solids
Anorexia is common
Nausea and vomiting can occur
during transition
Fetal Response to Labor
Persistent fetal heart rate changes
may indicate changes in fetal wellbeing
Fetal Response to Labor
Persistent fetal heart rate changes may
indicate changes in fetal well-being
Most fetuses are well equipped for
the stress of labor
Fetal Response to Labor
Persistent fetal heart rate changes may
indicate changes in fetal well-being
Most fetuses are well equipped for the
stress of labor
Initial assistance to the fetus is
provided through the mother
(position change, fluids, O2)
Fetal Response to Labor
Persistent fetal heart rate changes may
indicate changes in fetal well-being
Most fetuses are well equipped for the
stress of labor
Initial assistance to the fetus is provided
through the mother (position change,
fluids, O2)
A more thorough discussion is in
the section on fetal monitoring
Stages of Labor
Stage 1
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Onset of labor to complete dilatation (10 cms)
Stages of Labor
Stage 1
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onset of labor to complete dilatation (10cms)
Stage 2
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Complete dilatation to birth
Stages of Labor
Stage 1
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onset of labor to complete dilatation (10cms)
Stage 2
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Complete dilatation to birth
Stage 3
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Birth to delivery of the placenta
Stages of Labor
Stage 1
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onset of labor to complete dilatation (10cms)
Stage 2
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Complete dilatation to birth
Stage 3
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Birth to delivery of the placenta
Stage 4
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Delivery of the placenta until 1-4 hours after delivery
(depends on the mother)
First Stage of Labor
Phases
 Latent, also called early
Latent Phase of Labor
Lasts from onset until 4 cms dilated
Contractions: mild, 30-45 seconds long
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Regular and increasing in frequency, usually 5-10 minutes apart
Work: primarily effacement
Length:
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Primipara:8 hours, up to 24 hours
Multipara: 5 hours, up to 14 hours
Client is happy, talkative, outgoing
First Stage of Labor
Phases
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Latent
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Active
Active Phase of Labor
From 4 to 7 cm dilatation
Contractions: moderate, 45-60 seconds
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From 2-5 minutes apart
Work: Dilatation and descent
Length:
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Primipara: 4.5 hours, on average
Multipara: 2.4 hours, on average
Client becomes introspective, serious and tense
First Stage of Labor
Phases
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Latent
Active
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Transition
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Transition
From 8-10 cms dilated (10 cm is complete!)
Contractions: strong, last 60-90 seconds
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every 2-3 minutes
a “break” can occur at 10 cms, for 20 minutes or so, especially if Mom is
very tired
Work: descent and some dilatation
Length:
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Primiparas: 3.6
Multiparas: varies
Client discouraged, irritable. “Can’t do this!”
Second Stage of Labor
From complete dilatation to birth
Contractions last 60-90 seconds with strong intensity
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every 1.5-2 minutes
a “break” can occur at 10 cms, for 20 minutes or so, especially if
Mom is very tired
Lasts 15 minutes to 2 hours (average)
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With epidural, can be up to 3 hours
Perineum bulges, labia separate and head crowns
Behaviors in Second
Stage
Urge to bear down is strong
Pushing feels more productive to many mothers;
they are eager to push
Exhausted mothers may find the exertion
overwhelming
Burning as head crowns often causes fear of
“splitting open”
Pushing causes very intense sensations
that can frighten unprepared mothers
Pushing Techniques
Directed pushing
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Begins when mother is completely dilated
Patient takes two good breaths, then takes
and holds a third breath.
While holding the breath, she pulls back
her knees and pushes for a count of 10
Cycle repeated X 3
Pushing Techniques
Spontaneous Pushing
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Mother is encouraged to wait to push until the
urge to bear down is overwhelming
With some multips, this can occur at 8-10 cms
She is then told to breathe until the urge is strong,
push until she needs to breathe, and repeat until
the urge is gone
Urge usually strong at +1 station
Pushing starts 1-2 per contraction, can get to 3-4
pushes per contraction as head descends
Pushing Techniques
Waiting for the urge to push referred to
as “laboring down
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Urge to push with epidurals may not occur
until long after 10 cm
Studies show no advantage to directed
pushing
Laboring down and spontaneous
pushing result in shorter pushing times
and less fetal stress
Episiotomy
Surgical incision of the perineal body
Midline
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cut in a straight line along the median raphe
(from the vaginal orifice towards the rectum)
Divides the insertions of the perineal muscles
Mediolateral (usually right)
Begins in the midline of the
posterior fourchette (to avoid
Bartholin’s gland) and
extends at a 45 degree angle
downwards
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Benefits of Episiotomy
Hastens delivery if there is fetal
distress
May be needed if the perineum is
unyielding
May give more room for maneuvers
with shoulder dystocia
May give room for use of forceps or
vacuum
Risks of Episiotomy
Fecal and/or urinary incontinence
Pain in the area can persist for 6
months or more
Increased pain with intercourse
Bleeding
Bruising
Swelling
Infection
Third Stage of Labor
From birth of infant to delivery of the placenta
Lasts from 5-30 minutes
Contraction of the uterus decreases the surface
area under the placenta and causes the placenta to
“buckle”; a hematoma forms and extends, pushing
the placenta off the uterine wall
Third Stage of Labor
Signs of separation
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Uterus becomes globular
The fundus (top of the uterus) rises
Gush of dark red blood
Umbilical cord lengthens (as uterus
descends)
Gentle traction on the cord assists in
delivery and decreases bleeding
Hemorrhage is primary concern
Fourth Stage of Labor
Lasts 1-4 hours after delivery
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Beginning of physiologic readjustment of the
mother’s body
250-500 cc blood loss is common
Causes drop in systolic and diastolic
BP, tachycardia, increased pulse
pressure
Fourth Stage of Labor
Uterus is contracted, midline and near the
umbilicus
Oxytocin is given after delivery of the
placenta to increase uterine contraction and
decrease bleeding
Bladder may be hypotonic from anesthesia,
analgesia, trauma
Vital signs, fundal height and vaginal flow
checked every 15 minutes X 5 (1st hour)
Fourth Stage of Labor
Baby should be given to mother for
bonding and to initiate breastfeeding as
soon as possible
Shaking/chilling is common
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Ending of the physical exertion of labor
Most women are hungry, thirsty and
tired
Nursing Care During Labor
Admission assessment
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Date and Time of Admission
Primary Care Provider: Mom and Infant
EDC, Gravida / Parity
Allergies
Maternal Medical History
Medications Taken During Pregnancy
Problems with previous pregnancies
Nursing Care During Labor
Admission assessment (continued):
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Problems with this pregnancy
When labor started
Contraction pattern (frequency, duration,
intensity)
Any vaginal discharge
Membranes ruptured or intact:
amount/color/odor
Nursing Care During Labor
Admission assessment (continued)
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Fetal movement?
Fetal heart tone assessment/reactive?
Vital signs, including temperature
Vaginal exam for dilatation, effacement
and station
Labs: MBT, infectious status, GBS?
Psychological status
Electronic Fetal
Monitoring
External Contraction Assessment:
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Tocodynamometer (toco for short) placed at the top of the
fundus
Uterus rises and moves forward during the increment, then
reverses with decrement
Creates typical “hills” on monitor screen/paper
Appearance of the tracing depends on maternal position,
weight, parity
Electronic Fetal
Monitoring
External Fetal Assessment:
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Ultrasound transducer detects sound
waves
Prefers the loudest sound
Affected by position of the fetal heart
in relation to the transducer
Affected by thickness of maternal
abdomen
Electronic Fetal Monitoring
Internal Contraction
Assessment
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Internal Uterine Pressure
Catheter (IUPC)
Directly measure pressure
exerted by uterus in mmHg
Internal Fetal Assessment
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Fetal scalp Electrode (FSE)
Directly measure fetal heart rate
Can add assessment of shortterm/beat-to-beat variability
Fetal Heart Rate Monitoring
Baseline
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A 10 beat range that describes FHR between
contractions over a 10 minute time period
Normally 110 bpm to 160 bpm
Fetal Heart Rate Monitoring
Bradycardia: Below 110 bpm
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Moderate bradycardia from 81-110 bpm
Severe bradycardia less than 80 bpm for 2-3 minutes
Causes to consider
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Maternal hypotension (common with epidural)
Late (profound) fetal asphyxia
Prolonged umbilical cord compression
Fetal arrhythmia
Fetal Heart Rate Monitoring
Tachycardia: above 160 bpm
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Mild: 161-180 bpm
Severe: 181 bpm or greater
Fetal Heart Rate
Monitoring
Fetal tachycardia (continued)
Causes to consider
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Maternal fever
Dehydration
Betasympathomimetic drugs (e.g. terbutaline)
Early fetal hypoxia
Maternal hyperthyroidism
Fetal arrhythmia
Fetal anemia
Fetal Heart Rate
Monitoring
Variability
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Measure of the interplay of the
sympathetic and parasympathetic nervous
systems
Assessed as a sign of fetal well-being
Fetal Heart Rate
Monitoring
Long Term Variability
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Larger rhythmic fluctuations of
FHR
Occur 3-5 times per minute
Normal range of 6-10 bpm
Increases w/movement; decreases
with sleep
Classifications
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Decreased 0-5 bpm
Average/ moderate 6-25 bpm
Marked/ saltatory 25 bpm+
Fetal Heart Rate
Monitoring
Short Term Variability
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Difference between R wave
to R wave in successive
heartbeats
Represents actual
fluctuations from one
heartbeat to the next
Average 2-3 bpm
Classification
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Present or absent
Fetal Heart Rate Monitoring
Sinusoidal Pattern
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Wavelike baseline
Amplitude of 5-15 bpm
Regular oscillating pattern
2-5 cycles per minute
Absence of short or long
term variability
Associated with severe
asphyxia, Rh
isoimmunization, anemia,
fetal-maternal hemorrhage,
abruptions, or fetal
acidosis
Narcotics produce a
pseudosinusoidal pattern
Fetal Heart Rate
Monitoring
Accelerations
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Transient rises in fetal
heart rate above the
established baseline
Non-periodic
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Usually movement related
Two (2) 15 bpm
accelerations that last for
15 seconds = reactive
non-stress test
Periodic
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Response to stress of
contraction
Fetal Heart Rate
Monitoring
Decelerations
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Periodic decreases in fetal heart rate from
the baseline
Relationship to contractions and waveform
determines type of deceleration
Fetal Heart Rate Monitoring
Early decelerations
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Uniform in appearance
and mirror the
corresponding
contraction
Caused by pressure on
the fetal head
FHR rarely drops below
100 bpm or more than 30
bpm lower than baseline
Usually occur between 4-7
cm
Benign, unless the baby
is not descending into the
pelvis
Fetal Heart Rate Monitoring
Late decelerations
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Due to uteroplacental
insufficiency
Reflect decreased blood
flow during contractions
with decreased
oxygenation
Have a smooth uniform
shape (saucer-like)
Begin after contraction is
established and nadir is at
end of ctx
Often coupled with
decreased variability
Ominous, must be
treated/ provider notified
Fetal Heart Rate Monitoring
Variable decelerations
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Vary in onset, occurrence,
duration, intensity and
waveform
There is a visually abrupt
drop in FHR
Thought to be due to cord
compression
Positional or due to
decreased AFI
May be non-periodic or
periodic
If they last >60 seconds or
are less than 70 bpm, then
are a cause for alarm
Otherwise innocuous
Fetal Heart Rate Monitoring
Prolonged
decelerations
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FHR decreases from
the baseline for 2-10
minutes
Can be caused by
cord prolapse or
maternal hypotension
(with regional
anesthesia)
If baseline becomes
tachycardic, indicates
hypoxia and stress
Nursing Role in Labor
Accurate assessment of fetal response
to labor
Accurate assessment of maternal
response to labor
Accurate assessment of the emotional
responses of the woman and her
support system
Nursing Role in Labor
Interventions
Fetal Support-correct adverse FHR
changes
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Maternal hydration
Maternal oxygenation
Maternal position changes
Nursing Role in Labor
Maternal support: correct deficiencies
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Maternal nutrition and hydration
Maternal oxygenation
Pain coping
Facilatation of the maternal support
system
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Helping the support person to help the
mother
Suggestions and actual demonstration of
helpful behaviors
Nursing Role in Labor
Our role is
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To assure safe passage through the
transition of birth for mother and baby
To help birth a new family