Riverside School of Health Careers School of Professional Nursing RN 275 Maternal-Newborn Nursing Class notes- LABOR AND DELIVERY CULTURAL CONSIDERATIONS Values/beliefs r/t sickness and health Definition of childbirth experience Shameful? Joyful? Superstitions Taboos/expectations r/t food, drink, activity Family roles Definition of pain Significance of touch PHYSIOLOGY OF LABOR WHAT STARTS LABOR??? Factors that stimulate ctx: oxytocin, estrogen, fetal cortisol, prostaglandins Factors that quiet the uterine muscles: progesterone, adrenalin Theories: Cervical pressure ( prostaglandin release Uterine stretch theory – PTL?? Placental theory (progesterone withdrawal) PREMONITORY SIGNS OF LABOR: BRAXTON-HICKS contractions LIGHTENING ( s/s?? – feels like baby has dropped- easier breathing, gastric symptoms decrease, more pressure in pelvic region, pain in legs from pressure on nerves, constipation from pressure on bowels. SLEEP CHANGES (restlessness) – hard to find one position to get comfortable in, using the bathroom frequently. WEIGHT LOSS – usually only a pound or two r/t lack of appetite, diarrhea, etc. “NESTING” – getting ready for baby at home. “feathering the nest” gathering supplies and equipment and getting the room for the baby ready. MUCUS PLUG – dark reddish brown or sometimes it is fragments GI s/s ( n/v/d, indigestion - symptomatic of lack of progesterone BLOODY SHOW - cervix changes and little vascular eruptions of capillaries cause some bleeding (not a hemorrhage!) SROM – spontaneous rupture of membranes – water breaks on it’s own. Can be a trickle or it can be a big gush of fluid. LABOR: TRUE or FALSE? (Table 22-5) Premonitory symptoms present? FALSE: non progressive TRUE: longer, harder, closer together KEY = CERVICAL CHANGE NURSING PROCESS -- BEFORE ONSET OF LABOR ANXIETY r/t uncertainty about labor and ability to cope with pain HIGH RISK FOR INFECTION r/t SROM - LABOR STAGES AND PHASES STAGE 1: 0-10 cms dilated; 100% effaced PHASES: Latent, Active, Transition STAGE 2: full dilatation of cervix to birth of baby STAGE 3: delivery of baby to separation & expulsion of the placenta and membranes STAGE 4: first 1-2 hrs postpartum (up to 4 hrs) STAGE 1: “10 cms and 100%” first true ctx through full dilatation & effacement LATENT PHASE 0-3 cm ACTIVE PHASE 4-7 cm TRANSITION 8-10 cm CARDIOVASCULAR CHANGES: Cardiac output ( -more work going on in body Pulse: may be >100 bpm ( exhaustion or dehydration BP: ( if monitored during ctx; assess for supine hypotension – check BP in between contractions to get an accurate reading WBC: ( 20,000/mm³ in strenuous labor – not unusual to see FLUID & ELECTROLYTES: diaphoresis GASTROINTESTINAL CHANGES: N/V common r/t ( motility and absorption & ( gastric emptying time RENAL CHANGES: ( in concentrating urine Full bladder ( discomfort, impedes labor Pressure of presenting part on urethra ( cath? Proteinuria - (( BMR(basal metabolic rate), ?PIH RESULTS OF 1ST STAGE "RIPENING" of the cervix – cervix softens EFFACEMENT: % ( to paper-thin DILATATION: 0 to 10 cm (fully) STATION: Minus? 0? Plus? PRESENTATION: position, ROM MATERNAL ADMISSION ASSESSMENT VS, EFM, ctx, ROM, SVE Abdominal exam – Fundal height, Leopold’s Labs: H&H, WBC, type & screen, UA [STD, drug screens if necessary] Labor progress, meds Heart, lungs, DTRs/clonus Last PO intake? Psychologic state, support systems MATERNAL HISTORY: Prenatal record/hx EDC, GTPAL Allergies, med hx, OB hx, labs, CBE MATERNAL DISTRESS?? – difficulty coping, fears, anxiety, tension, etc FETAL ASSESSMENT: FHR, amniotic fluid leakage? If so then color and odor?, fetal movement kick counts? Absence in fetal movement? FETAL STRESS vs DISTRESS NURSING PROCESS --- 1ST STAGE OF LABOR RISK FOR INEFFECTIVE TISSUE PERFUSION r/t position in labor Discourage supine position Use hip wedge, LLR (left lateral recumb. position) Assess BP between ctx Frequent position changes URINARY RETENTION r/t progression of labor, bedrest, position, reluctance to move Monitor I&O Encourage PO fluids (popsicles, ice chips) Monitor IV intake Encourage bladder elimination q1-2 hrs FATIGUE r/t prolonged labor Latent phase: encourage rest, relaxation Active phase & transition: encourage rest between ctx Minimize environmental stimuli Offer comfort measures Offer/explain analgesia or anesthesia if indicated & desired FEAR r/t discomfort of labor Offer anticipatory guidance Orient to surroundings Give clear explanations of what to expect Maintain support system Encourage verbalization of source of fear INEFFECTIVE COPING r/t progress of labor Encourage expression of feelings Reinforce learned coping methods Maintain and assist support system Present new methods of coping Provide comfort measures PAIN (acute) r/t contractions and cervical dilatation Pain is a physiologic response to: cervical stretch receptors pressure on nerves traction on pelvic structures muscle hypoxia and ischemia PAIN RESPONSES… ADAPTIVE: rubbing, stroking, hot/cold applications, relaxation techniques MALADAPTIVE: thrashing, screaming, hyperventilating Fear-Tension-Pain cycle Cultural influences, socially learned negative responses, Judeo-Christian influences PAIN (acute) r/t contractions & cervical dilatation Acknowledge discomfort, monitor vs/FHT Document uterine activity and progress Comfort measures (nonpharmacologic pain relief) Breathing and relaxation techniques Empty bladder Frequent position changes Back rub, effleurage Cool cloth, warm compress Involve support person Analgesia & anesthesia as ordered/needed RISK FOR FLUID VOLUME DEFICIT r/t dehydration Monitor hydration status I&O, voiding q1-2h PO or IVF Monitor VS for deviations BP, P, R q30min s/s of bldg: ( pulse, ( BP T q4h (q2h after ROM); ( T ( dehydration Monitor FHR: s/s of distress r/t uteroplacental perfusion EFM or q15min RISK FOR INFECTION r/t SVEs & ROM Maintain good perineal hygiene ROM: note time & characteristics of AF Monitor temp q2h after ROM Monitor lab data as indicated Perform SVEs only as necessary (not students) Ensure aseptic technique during procedures Observe FHR for tachycardia NURSING CARE during 1st stage SAFETY – VS, FHT, danger s/s MOBILITY – ambulate/BR ?, reposition HYDRATION – IVs, PO ELIMINATION – to BR or bedpan q1-2h EMOTIONS – coaching, physical presence, hold hand, acknowledge hard work, support SO PAIN MGMT – psychoprophylactic, nonpharmacologic, analgesia PROGRESSION – continual assessment NURSING CARE: Physical Comfort Care Bed/underpad/gown Back care, massage, counterpressure OP baby? Side lying positions Effleurage Mouth care – ice chips, clean Cool cloth vs warm compress Bath/shower Leg cramps - dorsiflexion NURSING CARE intensifies as transition occurs… Emotional support – presence, reassurance, gentle but firm, pt. may reject touch/massage Pain intense, ctx long/hard, frightened, may be trembling – help stay focused! Physical comforts continue Multips: set up for delivery now Wake for next ctx S/S OF FULL DILATATION Bloody show, n&v, diaphoresis Perineal/rectal bulging, pass stool/urine Urge to push uncontrollable, satisfying? Vaginal introitus opening, caput visible!!, molding Burning/stretching sensation in perineum VS/FHR (early decels? maternal BP: supine hypotension ( fetal distress) PHYSIOLOGIC CHANGES OF THE 2nd STAGE OF LABOR Full dilatation to birth of infant Forces: ctx, presenting part, abdominal muscles bearing down Ctx: may be less frequent (q3-4 min & ~60 sec long); not as sharp; pushing “helps” frequency & duration may then build again to delivery NURSING DIAGNOSES – 2nd STAGE Urinary elimination, impaired r/t pressure of presenting part, epidural anesthesia Decreased cardiac output r/t expulsive efforts Ineffective coping r/t 2nd stage work Pain (acute) r/t contractions, fetal descent, perineal stretching Risk for infection r/t perineal laceration, vag exams NURSING CARE during 2nd stage Assess: recognize signs & symptoms early decels, ctx rate c/o BM & may pass stool, ( show “My baby’s coming!” Coach and encourage: assist with effective pushing, position praise, inform of progress remind to look at or touch baby’s head if desires PREPARE FOR DELIVERY Position --- elevate legs simultaneously, mirror, [OB scrubs & drapes pt] Asepsis --- observe sterile field, asepsis for prep … STANDARD PRECAUTIONS Birthing beds – LDR/LDRP --- more family centered Peri care – stroke away from vaginal opening toward rectum, change pads VS/FHT: EFM continual maternal BP q 5-15min can be stressful time for fetus & mom observe for distress Comfort – cool cloth, relax legs & body between pushes, may doze or even snore between cxns, alert before next ctx PHYSIOLOGIC CHANGES: 3rd STAGE OF LABOR SEPARATION AND EXPULSION OF PLACENTA FORCES: ctx manual removal prn by OB S/S: rising, globular shaped uterus firm ctx sudden gush of blood cord lengthens ~2-3” MECHANISMS: Duncan or Schultz (remember: “Shiny Shultz/ Dirty Duncan”!) NURSING DIAGNOSES -- 3rd STAGE Anxiety r/t concern for well-being of NB Risk for fluid volume deficit r/t blood loss from placental site PHYSIOLOGIC CHANGES OF THE 4TH STAGE----NURSING ASSESSMENT 1-2 hrs after delivery of placenta Fundus firm & ML, at or below the umbilicus Shaking / chills Pulse (; BP( Lochia rubra, occasional clots Recovery from anesthesia Thirsty or hungry, wide awake, talkative T( stable or ( NURSING CARE during the fourth stage Monitor mom’s & baby’s condition Q 15 minute assessmts: BP, P, fundus, lochia NB care & monitoring: color, respirations, Tº -- Keep the baby warm! Comfort care: warm blanket to mom, clean gown peri care, check epis/lac, void PO & IV fluids Assist with BF wash hands & nipples positioning Bonding touch, cuddle, talk to, ID parts may nurse Emotional support to patient & family may be talkative & relive experience or may be very tired & rest Very “teachable” moment! Assist MD as needed Document delivery & recovery [** NOTE: students do not chart.] Transfer to PP/MB when stable --- documentation complete & report to RN receiving patient NURSING DIAGNOSES -- 4th STAGE URINARY ELIMINATION, IMPAIRED r/t perineal edema, epidural anesthesia PAIN (acute) r/t involution, perineal trauma RISK FOR FLUID VOLUME DEFICIT r/t dehydration, blood loss RISK FOR INFECTION r/t placental wound, open cervix, perineal trauma, lochia Also: Immobility, impaired; Fatigue; Family processes, interrupted … IMMEDIATE CARE OF NEWBORN (NB) GOALS: RESPIRATIONS; THERMOREGULATION ACTIONS: Dry rubbing vigorously; Stimulate; Check respirations; Suction; O2 prn ESTABLISH RESPIRATIONS tactile stimulation; bulb suction mouth first, then nose [nose 1st ( laryngospasm which can ( ( O2, bradycardia] O2 prn per protocol THERMOREGULATION radiant warmer dry, warm blankets & hat remove wet blankets POSITIONING R side promotes closure of foramen ovale head down promotes drainage of secretions ASSESSMENT APGAR SCORE at 1 and 5 minutes Evaluates adaptive responses of NB: respiratory effort -- heart rate -- reflexes -- muscle tone -- color SCORE: 0-3 = poor 4-6 = fair 7-10 = good GOALS: ASSESSMENT AND IDENTIFICATION Physical assessment: Heart, murmurs Temperature (ax) Anomalies Lungs Cord (# vessels) Identification Footprints; Bands (baby x3, Mom, SO); HUGS tag Bonding “gradual, continual, reciprocal” Observe, encourage Quiet alert state x 45-60 min. --- excellent time to bond PHARMACOLOGY: OB PAIN RELIEF DRUGS THAT AFFECT THE CNS: Analgesics for labor pain: i.e. Stadol, Numorphan, Nubain Given w/ sedative / tranquilizer to potentiate analgesic Timing in labor crucial – Too early? Too late? Fetal / newborn effects? DRUGS THAT AFFECT THE CNS: ANESTHETICS Block nerve conduction when applied to nerve tissue Examples – Marcaine, Lidocaine, Ropivacaine REGIONAL BLOCKS – Local infiltration perineal at time of delivery)l EPIDURAL BLOCK (usually for labor- PCA pump) Spinal (Usu. for C/S) EPIDURAL ANESTHESIA Side Effects: HYPOTENSION urinary retention ( urge to push ( ( low forceps delivery platelets may ( Nursing care: left displacement of uterus IV bolus oximeter, EFM on during procedure assist with positioning, explain procedure BP q 2 min. x7 + per protocol O2 prn, vasopressor prn DRUGS THAT EFFECT THE CNS: Vasopressors Ephedrine Sulfate: increases BP; used to correct hypotension caused by epidural effects on perfusion DRUGS THAT EFFECT THE CNS: Antiemetic, Antianxiety, Antihistimine Phenergan: Antiemetic relieves side effects of narcotics -- nausea Atarax/Vistaril: Antiemetic, antianxiety; also: antihistamine, antipruretic; relieves side effect of epidural narcotic – itching Versed: Antianxiety; relieves apprehension, produces sedation SUMMARY: Methods of OB Pain Relief Psychoprophylaxis (Lamaze, etc.) Analgesics, Sedatives, Amnesics Anesthetics General: Inhalation, IV Regional blocks Local - perineal infiltration Spinal or epidural FETAL EFFECTS of PAIN MEDICATION! Effect on baseline FHR? BTBV? Possible decelerations? Fetal behavior? FM? Sleep? Delivery soon after dose of narcotic? LABOR & DELIVERY COMPLICATIONS EPISIOTOMY AND LACERATIONS: Episiotomy = incision in perineum to facilitate delivery, prevent lacerations, reduce time/stress OB MDs believe … Midwives believe … Types = midline/median [MLE] and R or L mediolateral LACERATIONS 1st degree 2nd degree 3rd degree - into anal sphincter 4th degree – into the rectal wall INDUCTION & AUGMENTATION Induction: artificial INITIATION of labor Augmentation: artificial STIMULATION of labor to enhance progress Prerequisites: engaged, fixed presenting part (low, not ballotable) vertex presentation ripe cervix (soft, partially dilated & effaced) term gestation (exceptions?) BISHOP CRITERIA: cervical readiness [dilatation, effacement, station, consistency,position] METHODS: "amniotomy, ambulate", strip membranes prostaglandins – gel, suppositories Foley bulb oxytocin - IV drip, secondary line, **via pump Cervical ripening protocol Must be confirmed live full term baby; Amnio for L/S ratio prn Cytotec 25 mcg q 5 h (p.o. or vaginal) Larger doses used for IUFD and Abortion DRUGS THAT EFFECT THE UTERUS: Uterine Stimulants Oxytocics used to: begin/enhance ctx prevent/control postpartum hemorrhage correct uterine atony in postpartum period cause uterine contractions after c/s or other types of uterine surgery induce therapeutic abortions after the first trimester 3 types of Oxytocics: Oxytocin (Pitocin); Ergots; Prostaglandins OXYTOCICS: Oxytocin (Pitocin) Stimulates smooth muscles of uterus & mammary glands Increases both frequency & force of uterine contractions Precise mechanism unclear If uterine contractions too forceful or too frequent ( fetal distress ( ** Stop infusion** half-life of oxytocin short (minutes) ( reversal of uterine stimulation effect rapid Ergot Derivatives ex. Methergine, Ergotrate produces powerful uterine contractions that are too strong for fetus; only used to control bleeding postpartum Prostaglandins comparable to oxytocin when used as oxytocic agent capable of stimulating uterine contractions during any stage of pregnancy Examples: Prostin E2, Prepidil, Cervidil USED AFTER DELIVERY ... Oxytocics - after placenta - why? Be ready with med and dose Pitocin 10-20 U in IVF or IM Up to 40 units of Pitocin (total) Nursing responsibilities? Side effects? Adverse drug rxns? If still bleeding, methergine and/or ergotrate (but not if BP ( -- then Pit only) INDICATIONS FOR INDUCTION Medical only Risks: uterine hypertonicity uterine rupture Fetal/neonatal bradycardia, decels tetanic contractions water intoxication Hyperbilirubinemia, Birth Trauma INDUCED PATIENT - MD must be available SAFETY: **PRIORITIZED nursing action in case of distress** (ie. tetanic ctx w/prolonged decel) “Big Five” 1. LLR position 2. O2 @ 8-10 LPM 3. IVF ( 4. Pit off 5. Call MD MORE VIGILANT NURSING… VS q15-30min EFM monitoring of FHT and ctx continuously Teaching - relaxation techniques, what to expect Emotional support Harder labor FORCEPS DELIVERY: INDICATIONS MATERNAL: maternal exhaustion; anesthesia impeding pushing efforts; prolonged 2nd stage; contraindication to push (eg. PIH, cardiac patient) FETAL: distress; failure to descend; mild dystocia or CPD; malpresentation; macrosomia Mid = 0 station (v. uncommon) Low = + station (most common) High = Negative station (NO!) COMPLICATIONS: MATERNAL: ? > pain; lacerations; uterine rupture; bladder / rectal trauma FETAL: facial marks or bruising; cephalhematoma; facial nerve damage; cord compression; skull fracture; intracranial hemorrhage VACUUM EXTRACTOR --- “Mighty-Vac” or KIWI Mechanism, indications same as forceps Complications in newborn: scalp bruise; cephalhematoma CESAREAN BIRTH Indications: dystocia, CPD previous C/S breech, malpresentation fetal distress "other”, including HSV & HPV Emergency vs non-emergency Patient response - fear, anxiety, or relief C/S ISSUES & NURSING CARE VARIATIONS 2 choices for skin incision: low abdominal incision (bikini cut, just cosmetic) or belly button down to pubic symphisis. 2 choices for uterine incision: Nursing care for prep of patient: physical; emotional; legal Nursing care r/t anesthesia: regional; general MORE C/S NURSING CARE... Nursing care to newborn: adaptations - bonding - Nursing care postpartum: Future prognosis -- VBAC? NURSING DIAGNOSES – C/S ANXIETY r/t surgical delivery, well-being of infant KNOWLEDGE DEFICIENT r/t cesarean birth PAIN (acute) r/t surgical incision, involution RISK FOR FLUID VOLUME DEFICIT r/t surgical procedure, blood loss RISK FOR INFECTION r/t surgical procedure SELF-ESTEEM, SITUATIONAL LOW r/t change in birth plan OTHER OB COMPLICATIONS IN L&D: AMNIOTIC FLUID EMBOLISM PLACENTA ACCRETA UTERINE ATONY (review PP Hem in PP Care) PAGE PAGE 12 © Riverside School of Health Careers, July 2006 01.10; rev. 10.10; 120810; 04.11; 07.11