Transcript Nursing Care - wcunurs206and216

Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Chapter 12--Processes &
Stages of Labor and Birth
Critical Factors
In Labor
 The Four P’s: passage, passenger,
powers & psyche
 Passage:
 adequate pelvis?
 cephalopelvic disproportion (CPD)
 Suspect if presenting part does not engage in
pelvis (0 station)
Passenger
 The fetus: head is largest diameter
 Fetal head: 4 bones with 3 membranous
interspaces (sutures) that allow bones to move &
overlap to diminish size of skull
 Molding: head becomes narrower, longer,
sutures can overlap--normal--resolves 1-2 days
after birth
 Fontanelles: at junctures of skull bones
Passenger
 Fetus and fetal membranes
 Molding of head
 Fetal lie
 Longitudinal
 Transverse
 Oblique
Fetal Lie
and Presentation
 Leopold's maneuvers/US
 Longitudinal lie: Vertical
 Presenting part:
 cephalic (head),
 vertex (occiput), chin (mentum)
 breech (buttocks or feet) (c-section)
 sacrum
 Transverse lie: Horizontal (c-section)
 Presenting part: shoulder (acromion)
Passenger (cont.)
 Fetal attitude—flexion
 Fetal presentation
 Cephalic
 Vertex
 Military
 Brow
 Face
Fetal Attitude
Advantages of
Cephalic Presentations
 Head usually largest part of infant
 Molding
 Optimal shape—smooth and round
Breech presentation
Assessment: FHT heard high on the abdomen,
Leopold’s, vaginal exam & US.
 Higher risk of anoxia from prolapsed cord, traumatic
injury to the after coming head,
fracture of spine or arm,
dysfunctional labor
 Usually delivered by
C-section
Disadvantages of
Breech Presentation
 Risk of cord prolapse
 Presenting part less effective in cervical
dilation
 Risk of cord compression
 Risk of prolonged labor
Shoulder Presentation
 Occurs when fetus in transverse lie
 Cannot be delivered vaginally unless
rotation occurs
IMPORTANT TERMS
 Effacement: shortening and thinning of
cervix
 Expressed as a percentage (0% to 100%)
 Dilation: opening and enlargement of
cervix
 Expressed in centimeters (1 to 10 cm)
Effacement
Thinning of cervix
(in %)
Station
Descent of fetal head
(in cm)
Descent of
fetal head:
Station
Floating
Engaged
At outlet/crowning
Passageway +
Passenger Relationship
 Engagement
 Station
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Ischial spines—0 station
Above ischial spines—(–) minus station
Below ischial spines—(+) plus station
+4 cm means that ...
Powers
 Uterine contractions—primary force
 Maternal pushing efforts—secondary force
 Characteristics of uterine contractions
 Increment
 Acme
 Decrement
Powers
Maternal Pushing Efforts
 “Bearing down” sensation
 Urge to push
 No urge to push
Assessment of
Uterine Contractions
 Characteristics
 Frequency
 Duration
 Intensity
 Palpation
 Electronic fetal monitoring
Onset of labor
 Usually begins between 38 & 42 weeks
 Mechanism is unknown
 Upper uterus contracts downward pushing
presenting part on cervix causing effacement
and dilatation
 Premonitory signs of labor:
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Lightening, Braxton-Hicks contractions (false labor),
cervical changes (ripening),
bloody show (mucous plug),
rupture of membranes (ROM),
sudden burst of energy
False vs True Labor:
Contractions
False Labor
 Benign and irregular
contractions
 Felt first abdominally
and remain confined to
the abdomen and groin
 Often disappear with
ambulation and sleep.
 Do not increase in
duration, frequency or
intensity
True Labor:
 Begin irregularly but
become regular and
predictable
 Felt first in lower back
and sweep around to the
abdomen in a wave
 Continue no matter what
the women’s level of
activity
 Increase in duration,
frequency, and intensity
False vs True Labor:
Cervix
False Labor
True Labor
 No significant
change in dilation
or effacement
 Progressive change
in dilation and
effacement
 No significant
bloody show
 Bloody show
 Fetus- presenting
part is not engaged
in pelvis
 Presenting part
engages in pelvis
Critical Thinking

A primigravida client has just arrived in the
birthing unit. What steps would be most important
for the nurse to perform to gain an understanding
of the physical status of the client and her fetus?
A. Check for ruptured membranes, and apply a fetal scalp
electrode
B. Auscultate the fetal heart rate between and during
contractions
C. Palpate contractions and resting uterine tone
D. Perform a vaginal exam for cervical dilation, and perform
Leopold's maneuvers
E. Determine gestational age of fetus
First Stage
of Labor:
 0 to 10 cm: dilatation--opening of cervix)
 Latent: slowest part of the process--slow
dilation, mild contractions
 from onset of regular UCs to rapid dilatation
(about 3-4 cms)
 Active: labor “picks up steam”--period of more
rapid dilation
 from 4 cm to full dilatation: stronger UCs
 Transition: 7-10 cm--intense, N/V, shaking
Landmarks
 Abbreviations are used
 First and last letter—maternal pelvis
 Middle letter—fetus presenting part
 Examples
 ROA (right occiput anterior)
 ROP
 LSP
Psychosocial
Influences
 Other critical factors
 Readiness, educational preparedness, etc.
 Cultural views of childbirth
 Role transition facilitated by positive
childbirth experience
 Negative experience interferes with
bonding and maternal role attainment
Childbirth Settings and
Labor Support
Admission
Procedures
 Establish positive relationship
 Collect admission data
 Initial admission assessments
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Focused
Psychosocial assessment
Cultural assessment
Laboratory tests
Nursing Care
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Ongoing assessment
Facilitate a positive birth experience
Manage discomfort
Advocate for patient’s needs
Provide anticipatory guidance
Care of Laboring Patient Early Labor
Couple excited, talkative, pain is manageable
 Initial physical
assessment & history
 Admission--rapport
 Fetal & UC
monitoring
 Vaginal exams, q 2
hours
 Vital signs
 Temperature q 4
hours-intact or q 2
hours ROM
 Educate regarding
labor
 Encourage comfort,
position changes,
bladder emptying
 Assess pain, pain
tolerance, preferred
type of labor/delivery
 Reassure regarding
what is normal,
reduce anxiety
Care of Laboring Patient Active Labor
Couple quieter, discouraged, pain increasing
 Transition (7-10 cm): Yikes! “out of control”,
shaking, nausea/vomiting, sweating, pain is
intense
 Prepare for delivery
 Second stage (Pushing):
 Educate/instruct regarding pushing
 Assess urge to push and fetal descent
 Encourage/motivate patient, assess fatigue
 Monitor fetal/maternal response to pushing
bulge, crowning
 Signs of imminent birth: perineal bulging
Labor Support
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Presence
Promote comfort
Environment
Personal hygiene
Elimination
Supportive relaxation techniques
Critical Thinking
A client is admitted to the labor unit with contractions 2 to 3
minutes apart and lasting 60 to 90 seconds. The client is
apprehensive and vomiting. This nurse understands this
information to indicate that the client is most likely in what
phase of labor?
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A) Active
B) Transition
C) Latent
D) Second
Fetal Assessment
 Position
 Fetal heart sounds
 Baseline FHR
 Presence of
 Variability
 Accelerations
 Decelerations
Interpretation of
FHR Tracings
 Consider contraction frequency and
intensity, stage of labor, and earlier FHR
pattern
 Reassuring
 Non-reassuring
Nursing Care
 FHR decelerations
 Early: no action
 Variable and late
 Lateral position changes
 Oxygen per face mask
 Palpation for hyperstimulation
 Discontinue oxytocin
 Increase IVF rate
Second Stage
of Labor
 Full dilation through birth of infant
 Urge to push
 Promote effective pushing
 Closed-glottis
 Open-glottis
 Position of comfort
Preparation
for Birth
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Bulging of the perineum and rectum
Flattening and thinning of the perineum
Increased bloody show
Labia begin to separate
Dilatation & Effacement
Imminent Birth
 Crowning
 Burning sensation
 Intense pressure in rectum
Mechanisms of labor. A, Descent. B, Flexion.
C, Internal rotation. D, Extension. E, External rotation.
Cardinal Movements
of Birth
Head Rotation during Descent
Crowning
Crowning
Alternative settings
In the hospital
Nursing Diagnoses
for Intrapartal Patient
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Pain
Knowledge deficit
Anxiety
Fatigue
Risk for infection
Impaired fetal gas exchange
Third Stage
 Birth of baby to complete delivery of
placenta
 Smaller, spherical uterus
 Elevation of uterus in abdomen
 Lengthening and protrusion of cord
 Gush of blood from vagina
Fourth Stage
 Delivery of placenta
through 1 to 2 hours after birth
 Monitor position and firmness of uterus
 “Boggy,” soft uterus
 Report immediately
 Initiate fundal massage
 Assess lochia
 Vital signs and urine output
 Shivering—offer blankets
Fourth Stage
—Risk Signs
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Hypotension
Tachycardia
Excessive bleeding
Noncontracting uterus
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Chapter 13
Promoting Patient Comfort During
Labor and Birth
Pain
During Labor and Birth
 Shaped by past experiences
 Assessing pain
 Physiological, psychological indicators
 Patient responses
 May be intensified by fear, anxiety, fatigue
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Physical Causes of Pain
Labor and Birth
Susan Ward
Shelton Hisley
Pain Neurology
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Uterine ischemia
Visceral pain—dull and aching
Referred pain
Somatic pain—sharp, burning, prickling
Pain Perception
and Expression
 Highly personal and subjective
 Affected by gender, culture, ethnicity, and
past experiences
 Physiological/affective expression
 Increased catecholamines
 Increased blood pressure and heart rate
 Altered respiratory pattern
Factors Affecting
Maternal Pain Response
 Physical
 Physiological
 Psychological
 Anxiety, fear, previous experience
 Support systems, childbirth preparation
 Environmental
Nonpharmacological
Pain Relief Measures
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Maternal position and movement
Breathing techniques
Music
Relaxation techniques
Other attention-focusing strategies
 Guided imagery
Massage and Touch
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Effleurage
Counterpressure
Therapeutic touch
Healing touch
Other Therapies
for Comfort
 Hydrotherapy, hypnotherapy,
aromatherapy
 Application of heat and cold
 Biofeedback, TENS, intradermal water
block
 Acupressure/acupuncture
Pharmacological
Pain Relief Measures
 Timing
 Nonpharmacological and pharmacological
measures promote positive experience
 Informed consent
Pharmacological
Measures
 Sedatives and antiemetics
 Systemic opiods & analgesics
Nerve Block Analgesia,
Anesthesia
 Regional anesthesia- Epidural
 Local perineal infiltration anesthesia
 Pudendal nerve block
 Spinal anesthesia block
 Complications: maternal hypotension, decreased
placental perfusion, ineffective breathing pattern
Systemic Analgesia
 Pre-medication Assessment:
 Pain level, VS, allergies, drug dependence
(withdrawal), vaginal exam/progress in labor, UC
pattern, fetal heart rate tracing
 Post-medication Assessment:
 VS, esp. RR, LOC, dizziness (bedpan), sedation,
FHR
 Reversal agent: Naloxone (Narcan)
 Competes with narcotic for opiate receptors.
Used in both mom and baby. (avoid with narcotic
dependence)
Regional Anesthesia
Definition: Injection of local anesthesia to block
specific nerve pathways
• Epidural/spinal anesthesia
• Systemic toxicity: cardiovascular collapse
• Side effects: Hypotension (preload with IV
fluids), fetal distress on FHR tracing, spinal
HA
• Contraindications: coagulation disorders, low
platelet count (< 100), allergy, neurologic
disease, aspirin or heparin use
 Nursing care: Preload IV fluids (LR), monitor
BP, HR, anesthesia level, FHR, foley catheter,
maternal positioning
Maternal Hypotension
 Prevention
 Preload IV fluids
 Requires constant nursing attendance
 Monitor vital signs
Epidural Anesthesia
Postdural Puncture
(Spinal) Headache
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Leakage of cerebrospinal fluid
Intensified in upright position
Auditory and visual problems
Autologous epidural blood patch
 Discharge instructions
Disadvantages
of Epidural
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Limited mobility
Common side effects
Accidental injection into blood vessel
Sympathetic blockage
Urinary retention, bladder distention
General Anesthesia
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Major risks –used ONLY in emergencies
Pre-operative preparation
Anesthetic gases and medications
Recovery room nursing care
Nursing Care
Related to Comfort Measures
 Assessment
 Ongoing and collaborative
 Diagnoses
 Anxiety
 Ineffective coping
 Acute pain
Nursing Care
 Expected outcomes
 Plan of care
 Individualized
 Modified as needed
 Collaborative approach
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 14
Caring for the Woman
Experiencing Complications
During Labor and Birth
Susan Ward
Shelton Hisley
Dystocia
 Long, difficult, or abnormal labor
 May arise from
 Powers
 Passenger
 Passageway
Dysfunctional Labor Pattern:
Hypertonic
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Strong, painful, ineffective contractions
Contributing factor—maternal anxiety
Occiput-posterior malposition of fetus
Management
 Rest, hydration, sedation
 Facilitate rotation of the fetal head
Dysfunctional Labor Pattern:
Hypotonic
 Contractions decrease in frequency and
intensity
 Maternal and fetal factors that produce
excessive uterine stretching
 Management
 Walking, position changes
 Augmentation of labor
Precipitate Labor
and Birth
 Rapid labor & birth
 Nursing considerations
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Careful examination for dilation and effacement
Reassure woman and support person
Breathing to avoid pushing and prevent tearing
Careful examination of maternal soft tissue and
placenta
Pelvic Structure Alterations
 Pelvic dystocia
 Soft tissue dystocia
 Trial of labor
 To assess safety of vaginal birth
Obstetric Interventions
Amniotomy
 Artificial rupture of membranes
 Augment or induce labor
 Nursing
 Careful monitoring of vital signs, cervical
effacement/dilation, station, FHR, contractions
 Document regarding amniotic fluid
Obstetric Interventions
Amnioinfusion
 Risks: infection, overdistention of uterus,
increased uterine tone
 Nursing
 Careful monitoring of infusion, intensity and frequency
of contractions, and maternal vital signs
 Educate
 Pharmacological induction of labor
 Nonpharmacological stimulants of labor
Episiotomy
 Midline or mediolateral
 Nursing care:
 Assess for
approximation,
swelling, oozing,
infection
 Relief for pain: ice
pack in first 24
hours, then heat,
local analgesic
spray, witch hazel
pads (Tucks), sitz
bath, peri-bottle for
voiding, pain
medications
Induction of Labor
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Indications for induction
Bishop score
Cervical ripening agents
Mechanical methods
Oxytocin
Augmentation of labor
Induction—Nursing
Considerations
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Informed consent
Careful monitoring of labor
Discuss pain relief measures
Position changes
Keep patient and support person informed
of progress
Instrumentation Assistance
of Birth
 Forceps
 Indications: unable to push, arrested descent,
need a quick delivery, breech
 Associated with: maternal/fetal birth trauma, rectal
sphincter tear, urinary stress incontinence
 Vacuum extraction
 Advantages: fewer lacerations, less anesthesia
needed,
 Disadvantages: marked caput,
cephalhematomas, scalp laceration/bruising
Maternal Complications
Hypertensive
Disorders
 Preeclampsia-eclampsia, HELLP syndrome
 Nursing
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Careful assessments
Monitor lab values
Administer platelets as appropriate
Ongoing education
Maternal Complications
Diabetes
 Fetal lung maturity
 Intrapartum management
-Maternal hydration,
-Insulin, and
-Blood glucose levels
 Labor: normal progression of labor
 Upright or side-lying position
 Encourage breastfeeding
Preterm Labor
and Birth
 Careful maternal monitoring
 FHR monitoring ***
 Identify and report symptoms suggestive of
fetal hypoxia
 Assess psychological status
Labor and Birth
Complications
Fetal
 Fetal malpresentation
 Version: external or internal
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Shoulder dystocia
Cephalopelvic disproportion
Multiple gestation
Non-reassuring FHR patterns
Macrosomia/Shoulder Dystocia
 Wt. > 4500 gms (9-10 lbs)
 Associated with:
 DM, Gestational DM, Multiparity, Postdates, obesity
 Risks:
 Shoulder dystocia, difficulty delivering the shoulders after
head is delivered (obstetrical emergency)
 Maternal: vaginal/cervical tears, pp hemorrhage, rupture
 Fetal: compressed cord, fractured clavical, asphyxia &
neurologic damage, brachial plexus injury (Erb’sPalsy)
 S/S: Turtle sign
 Nursing interventions: McRoberts maneuvers,
suprapubic pressure. PP: assess for uterine
atony/hemorrhage; trauma, cerebral or neurologic
damage to baby
Video: youtube.com/watch?v=jV6g427UMxY&feature=related
McRoberts Maneuvers Video
Amniotic Fluid
Complications
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Oligohydramnios
Hydramnios
Meconium
Nuchal cord
Other Complications
 Uterine rupture
 Obstetric emergency
 Uterine inversion
 Umbilical cord prolapse
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Collaboration in Perinatal
Emergencies
Perinatal Fetal Loss
 What to say
 What NOT to say
 Nursing considerations
< 20 weeks
> 20 weeks
name & hold the baby
funeral/memorial service
Resolve support group
Cesarean Birth
 Indications
 Health of mother or fetus is jeopardized
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Ethical considerations
Surgical procedures
Surgical and postoperative care
Vaginal birth after cesarean
Cesarean Birth
Indications for:
Maternal Factors
Placenta Factors
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 Placenta previa
 Placental abruption
 Umbilical cord prolapse
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Active genital herpes
AIDS/HIV +
Cephalopelvic disproportion
Severe preeclampsia,
diabetes
Obstructive tumor
Ruptured uterus
Previous c-section
Failed induction/fx to progress
in labor
Elective?
Fetal Factors
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Breech, transverse lie
Macrosomia
Extreme low birth wt
Fetal distress
Fetal anomalies
Multiple gestation
Maternal Complications
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Infection
Anesthesia reactions
DeepVeinThrombophebis
Bleeding
Ureteral/bladder injury
Increase risk for
subsequent pregnancy
 Placenta
Acreta/Previa,
Infertility
Cesarean Birth
(cont)
 Mortality/morbidity
 4 x higher than
vaginal birth in US.
Most risk assoc. with
emergency c-section
 Incision
 Skin vs. uterine
 Classical vs low
transverse
Postterm Pregnancy
 > 42 weeks
 Maternal risks: trauma/hemorrhage due
to larger baby, ↑operative delivery/csection
 Fetal risks: placental changes that
↓oxygenation to baby and ↑mortality rate,
oligohydramnios (↑cord compression
during labor), LGA baby (↑birth trauma,
shoulder dystocia), meconium aspiration
 Management: > 40 wks, NST, BPP or
modified BPP (NST & AFI), induction
Post-Op Care
 Assess fundus/bleeding, vital signs, DVT.
 Antibiotics, if infection
 Pain: Duramorph. Breakthrough pain
meds. Benadryl for itching. Zofran for
nausea.
 Clear liquids and advance as tolerated.
 Assess for GI function. Bowel sounds?
Passing flatus?
 Ambulation. Pre-medicate, teach splinting
with pillow.
Critical Thinking
 A laboring multipara is
having intense uterine contractions
with incomplete uterine relaxation between
contractions. Vaginal examinations reveal rapid
cervical dilation and fetal descent.
What should the nurse do first?
A) Notify the physician of these findings.
B) Place the woman in knee-chest position.
C) Turn off the lights to make it easier for the
woman to relax.
D) Assemble supplies to prepare for birth.
Case Study: Linda Mandella
Linda Mandella is in labor with her third baby at the birth center.
She wishes to experience a natural, unmedicated birth. Linda is groaning
and crying. A cervical examination performed 2 hours ago revealed that
she was 6 cm dilated, and 100% effaced.
Linda’s family is present, and this is the first time that they have been able
to attend and support her during the labor and birthing process. The family
members are shouting and blaming the nurse for causing Linda to suffer.
They demand that the nurse give Linda painkillers to ease her suffering and
pain.
Critical Thinking Questions
 1. What are the priority nursing diagnoses at this time?
 2. What are the expected outcomes associated with these diagnoses?
 3. Describe the teaching/learning needs related to the scenario that
correspond to the priority nursing diagnoses.
 4. List nursing interventions with rationales that correspond to the priority
nursing diagnoses.