Labor And Delivery
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Labor and Delivery Terminology “Lie”—The relationship of the long axis of the fetus to the long axis of the uterus. Longitudinal or transverse “Presentation”—That part of the baby lowest in the pelvis Vertex or cephalic 96—97% of the time Breech 3-3.5 % of the time Terminology continued “Attitude” refers to the degree of flexion of the fetus. Complete flexion is the best attitude “Position” refers to the relationship of the presenting part of the fetus to the pelvic quadrants of mother. The occiput is the point of reference for the cephalic presentation. Terminology “Station” refers to the location of the presenting part of the fetus as it makes it descent into the true pelvis. Point of reference is the ischial spines. Floating is above the spines. Engaged is the level of the spines. “Lightening” is another term for engagement. Terminology “Effacement” refers to the thinning out of the cervical canal. It is expressed in percentages. Primigravidas usually efface more quickly than they dilate. Multiparas typically will experience effacement and dilatation at the same time. Terminology “Dilatation” refers to the stretching of the cervix to accommodate delivery. Complete dilatation is 10 Centimeters Uterine contractions provide the force “Show” refers to the blood tinged mucosy vaginal discharge. The mucous plug is dislodged Becomes more bloody as labor progresses. MECHANISMS OF LABOR Descent or lightening Flexion Internal Rotation Extension External Rotation Expulsion or birth Fetal Aspects of Labor The fetal skull is not ossified. There are fontanels and interspaces to allow for molding of the fetal head.
The
anterior fontanel is diamond shaped at the junction of the two frontal bones and the two parietal bones. The Fetal Skull The posterior fontanel is smaller and is triangular in shape at the junction of the occipital bone and the parietal bones. The interspaces or suture lines are: Sagital—between the parietal bones Coronal—between the frontal and parietal bones. Lambdoid—between the occipital bone and the parietal bones. Impending Labor (Preliminary signs) Lightening—the settling down into the true pelvis Burst of energy and increase in activity level. Braxton-Hicks contractions may be confused as false labor. Ripening of the cervix. Rupture of the membranes. Show—vaginal discharge. True Labor The onset of regular contractions that show a pattern. They will come at regular intervals and as labor progresses will be closer together. They will increase in intensity. They will increase in length or duration. True Labor Contractions are involuntary. But mother can work with them to decrease her discomfort and increase the effectiveness. There are three phases: Increment—building up Acme—height of intensity Decresendo—begins to relax Relaxation interval is also important. Evaluating Contraction Pattern Timing of the contractions is important and can be felt at the fundus. Interval or frequency is from the beginning of one to the beginning of the next. Duration is how long the contraction lasts. Intensity is the strength of the contraction. Relaxation interval is the period in between contractions. Stages of Labor Stage One is the “Dilating” stage. Latent phase Active phase Transitional phase Stage Two is the “Birthing” stage. Stage Three is the “Placental” stage. Stage Four is the “Recovery” stage.
Nursing Care in Labor/delivery On Admission need to be calm and reassuring. Mother may be stressed and tired. Collecting data: Need to know EDC, previous OB history, pre-natal care. Onset of labor—contractions, bloody show, condition of membranes. Vital signs—mother and baby. Lab Work on Admission Urinalysis—voided or catheterized in Delivery. Protein Glucose Bacteria Blood work: CBC H & H VDRL or RPR Type GBS Nursing Care During Labor During Latent phase: Vital signs and interview on admission Encourage activity and ambulation (if ROM intact). Provide information regarding what to expect. Diet may be only clear liquids or NPO. Nursing Care During Labor During Active phase: Mother will be concentrating more on her labor. Assess her ability to cope and effectiveness of her support system. Never leave mother in active labor alone. Offer opportunity to void every two hours. Usually will be NPO with IV fluids to provide for hydration and medications as needed. Nursing Care During Labor Transitional phase: This is the last bit of stretching that must be done before birth. Most difficult part of the labor process. Prepare for delivery At complete dilatation for primigravida At 7-8 cm for multipara Nursing Care During Labor Continue to offer opportunity to void as needed. Vital signs for mother and baby more often.
Signs
you might observe are: Nausea/vomiting Involuntary shaking/tremors of the legs Mood change Desire to push Nursing Care During Labor With rupture of membranes: May be SROM or AROM Assess fetal condition by noting FHT’s Note amount and color of fluid: Meconium staining With PROM these additional problems may occur. Infection Prolapsed cord Preparation for Delivery Provide for cleanliness throughout labor. Perineal cleansing Prepare sterile table and equipment. Provide emotional supportive care to patient and family. Notify physician . Evaluating the Fetal Condition The fetal heart tones are the best indicator of fetal condition. Can be assessed with fetoscope, doppler, or monitor. Best to listen during or immediately following a contraction to determine fetal distress. The Fetal Heart Tones The location they are best heard can be an indicator of fetal position. Above
the umbilicus may be a breech position.
Below
the umbilicus probably indicates a vertex presentation.
The Fetal Heart Tones The location can also indicate fetal descent. May be heard in the side at the level of umbilicus at first. As progress is made in descent will be closer to midline and lower. Just prior to birth may be in midline just over the pubic bone. The Fetal Heart Tones Generally will need to establish a baseline for each baby. Average range for normal FHT’s is 120 to 160 beats per minute. Should have beat-to-beat variability of 6 – 10 per minute. Reduced variability may be due to sedatives/analgesics given to mom, or fetal sleep or inactivity. The Fetal Heart Tones Persistent fetal tachycardia may be due to:
Maternal fever Preterm labor Fetal hypoxia Persistent fetal bradycardia may be due to: Maternal hypotension
Decelerations of Fetal Heart Tones May indicate fetal distress. Should be evaluated in relation to the contractions. Early decels are early in the contraction as it is beginning. Late decels occur late toward the end of the contraction. Variable decels do not show any typical pattern in relation to the contractions. Decelerations of the FHT’s Early decelerations probably are due to head compression with the contractions. These usually have a rapid recovery to baseline. Do not require any nursing intervention. Decerlerations Late decelerations are probably due to utero-placental insufficiency. These usually are delayed recovery to baseline. Nursing interventions required: Turn to the left-side lying position Oxygen given at 8-10 liters Turn off or reduce the rate of pitocin Decelerations Variable decels are likely due to cord compression. These usually also are delayed to recover to baseline. This may be due to position of baby in utero, or prolapsed cord. Position patient to relief pressure and notify physician. Nursing Care During Stage Two Continue to assess vital signs of mother and baby more often as labor progresses. Watch for signs of impending birth: Bulging perineum Crowning Dilated anus Uncontrollable urge to push Perineal cleansing prep. Notify physician Danger Signals to Note Abnormal vaginal bleeding Cessation of contractions after labor established Elevated B/P, sever headaches, blurred vision Elevated temperature, pulse, respirations Rigid uterus after contraction Exhaustion
Danger Signals Irregular fetal heart rate: Persistent tachycardia Persistent bradycardia Decelerations Meconium-stained amniotic fluid Hyperactivity of the fetus Prolapsed of the cord Assisted Deliveries Forceps may assist mother in delivery to shorten the 2nd stage of labor. Mother may be exhausted and unable to push. Baby may be showing of fetal distress. Low outlet forceps may be used. Vacuum extraction is another method. Care of the Infant Airway clearance and establishment of independent respirations are the first priority. Warmth is of immediate concern as well. Cord is clamped and cut. Bonding –give baby to parents as soon as possible. Assessment of Neonate Apgar Assessment Results Rating of 7 – 10 is a vigorous newborn. Rating of 4 – 6 is a moderately depressed newborn who may require some intervention. Rating of less than 3 is s severely depressed baby who will require intervention. Prophylactic Care Eye treatment To prevent ‘opthalmic neonatorum’ Conjunctivitis from gonorrhea or clamydia Ilotycin, Tetracycline, Silver Nitrate Aquamephyton To prevent bleeding problems in newborn. Vitamin K is given as one time dose of 0.5-1 mg. Other Needs of the Newborn Identification is very important. Triple band bracelets are commonly used. Baby’s footprints and mother’s thumb prints are used, as well as a photo. Security is also an important concern. The OB area is a locked, secured unit. Nursing Care During Stage Three Placenta is delivered following birth of the baby. Pitocin hastens delivery of the placenta and is usually given at this point. Signs of placental separation are: Globular shape and firm uterus Lengthening of the cord
Gush of blood or increase in bloody flow. Stage Three Mechanism of placental delivery are: Schultze Mechanism--80% of the time the shiny fetal surface is seen first. Duncan Mechanism—20% of the time the dull maternal surface escapes first. The placenta will be carefully inspected after delivery For abnormalities For completness Nursing Care During Stage Four Early Post-partum recovery—the first 1-2 hours after delivery. Careful observation and assessment is of utmost importance and may be done every 15 minutes during the first hour. Check B/P, Pulse Fundal tone and location Lochial flow Perineal assessment
Stage Four continued Hemorrhage is the number 1 priority of concern at this time. Pitocin may be use to control P-P bleeding. Warmth is also a need during this period. May be hungry and thirsty. Allow for privacy with family for bonding. Special Situations Precipitate delivery Cerebral trauma for baby Risks for lacerations for Mom Breech presentations Cerebral trauma for baby Longer, more difficult labor for Mom Twin (Multiple) Births Premature births Maternal risks PIH, P-P bleeding nd Delivery of 2 twin often more problems
The
anterior fontanel is diamond shaped at the junction of the two frontal bones and the two parietal bones. The Fetal Skull The posterior fontanel is smaller and is triangular in shape at the junction of the occipital bone and the parietal bones. The interspaces or suture lines are: Sagital—between the parietal bones Coronal—between the frontal and parietal bones. Lambdoid—between the occipital bone and the parietal bones. Impending Labor (Preliminary signs) Lightening—the settling down into the true pelvis Burst of energy and increase in activity level. Braxton-Hicks contractions may be confused as false labor. Ripening of the cervix. Rupture of the membranes. Show—vaginal discharge. True Labor The onset of regular contractions that show a pattern. They will come at regular intervals and as labor progresses will be closer together. They will increase in intensity. They will increase in length or duration. True Labor Contractions are involuntary. But mother can work with them to decrease her discomfort and increase the effectiveness. There are three phases: Increment—building up Acme—height of intensity Decresendo—begins to relax Relaxation interval is also important. Evaluating Contraction Pattern Timing of the contractions is important and can be felt at the fundus. Interval or frequency is from the beginning of one to the beginning of the next. Duration is how long the contraction lasts. Intensity is the strength of the contraction. Relaxation interval is the period in between contractions. Stages of Labor Stage One is the “Dilating” stage. Latent phase Active phase Transitional phase Stage Two is the “Birthing” stage. Stage Three is the “Placental” stage. Stage Four is the “Recovery” stage.
Nursing Care in Labor/delivery On Admission need to be calm and reassuring. Mother may be stressed and tired. Collecting data: Need to know EDC, previous OB history, pre-natal care. Onset of labor—contractions, bloody show, condition of membranes. Vital signs—mother and baby. Lab Work on Admission Urinalysis—voided or catheterized in Delivery. Protein Glucose Bacteria Blood work: CBC H & H VDRL or RPR Type GBS Nursing Care During Labor During Latent phase: Vital signs and interview on admission Encourage activity and ambulation (if ROM intact). Provide information regarding what to expect. Diet may be only clear liquids or NPO. Nursing Care During Labor During Active phase: Mother will be concentrating more on her labor. Assess her ability to cope and effectiveness of her support system. Never leave mother in active labor alone. Offer opportunity to void every two hours. Usually will be NPO with IV fluids to provide for hydration and medications as needed. Nursing Care During Labor Transitional phase: This is the last bit of stretching that must be done before birth. Most difficult part of the labor process. Prepare for delivery At complete dilatation for primigravida At 7-8 cm for multipara Nursing Care During Labor Continue to offer opportunity to void as needed. Vital signs for mother and baby more often.
Signs
you might observe are: Nausea/vomiting Involuntary shaking/tremors of the legs Mood change Desire to push Nursing Care During Labor With rupture of membranes: May be SROM or AROM Assess fetal condition by noting FHT’s Note amount and color of fluid: Meconium staining With PROM these additional problems may occur. Infection Prolapsed cord Preparation for Delivery Provide for cleanliness throughout labor. Perineal cleansing Prepare sterile table and equipment. Provide emotional supportive care to patient and family. Notify physician . Evaluating the Fetal Condition The fetal heart tones are the best indicator of fetal condition. Can be assessed with fetoscope, doppler, or monitor. Best to listen during or immediately following a contraction to determine fetal distress. The Fetal Heart Tones The location they are best heard can be an indicator of fetal position. Above
the umbilicus may be a breech position.
Below
the umbilicus probably indicates a vertex presentation.
The Fetal Heart Tones The location can also indicate fetal descent. May be heard in the side at the level of umbilicus at first. As progress is made in descent will be closer to midline and lower. Just prior to birth may be in midline just over the pubic bone. The Fetal Heart Tones Generally will need to establish a baseline for each baby. Average range for normal FHT’s is 120 to 160 beats per minute. Should have beat-to-beat variability of 6 – 10 per minute. Reduced variability may be due to sedatives/analgesics given to mom, or fetal sleep or inactivity. The Fetal Heart Tones Persistent fetal tachycardia may be due to:
Maternal fever Preterm labor Fetal hypoxia Persistent fetal bradycardia may be due to: Maternal hypotension
Decelerations of Fetal Heart Tones May indicate fetal distress. Should be evaluated in relation to the contractions. Early decels are early in the contraction as it is beginning. Late decels occur late toward the end of the contraction. Variable decels do not show any typical pattern in relation to the contractions. Decelerations of the FHT’s Early decelerations probably are due to head compression with the contractions. These usually have a rapid recovery to baseline. Do not require any nursing intervention. Decerlerations Late decelerations are probably due to utero-placental insufficiency. These usually are delayed recovery to baseline. Nursing interventions required: Turn to the left-side lying position Oxygen given at 8-10 liters Turn off or reduce the rate of pitocin Decelerations Variable decels are likely due to cord compression. These usually also are delayed to recover to baseline. This may be due to position of baby in utero, or prolapsed cord. Position patient to relief pressure and notify physician. Nursing Care During Stage Two Continue to assess vital signs of mother and baby more often as labor progresses. Watch for signs of impending birth: Bulging perineum Crowning Dilated anus Uncontrollable urge to push Perineal cleansing prep. Notify physician Danger Signals to Note Abnormal vaginal bleeding Cessation of contractions after labor established Elevated B/P, sever headaches, blurred vision Elevated temperature, pulse, respirations Rigid uterus after contraction Exhaustion
Danger Signals Irregular fetal heart rate: Persistent tachycardia Persistent bradycardia Decelerations Meconium-stained amniotic fluid Hyperactivity of the fetus Prolapsed of the cord Assisted Deliveries Forceps may assist mother in delivery to shorten the 2nd stage of labor. Mother may be exhausted and unable to push. Baby may be showing of fetal distress. Low outlet forceps may be used. Vacuum extraction is another method. Care of the Infant Airway clearance and establishment of independent respirations are the first priority. Warmth is of immediate concern as well. Cord is clamped and cut. Bonding –give baby to parents as soon as possible. Assessment of Neonate Apgar Assessment Results Rating of 7 – 10 is a vigorous newborn. Rating of 4 – 6 is a moderately depressed newborn who may require some intervention. Rating of less than 3 is s severely depressed baby who will require intervention. Prophylactic Care Eye treatment To prevent ‘opthalmic neonatorum’ Conjunctivitis from gonorrhea or clamydia Ilotycin, Tetracycline, Silver Nitrate Aquamephyton To prevent bleeding problems in newborn. Vitamin K is given as one time dose of 0.5-1 mg. Other Needs of the Newborn Identification is very important. Triple band bracelets are commonly used. Baby’s footprints and mother’s thumb prints are used, as well as a photo. Security is also an important concern. The OB area is a locked, secured unit. Nursing Care During Stage Three Placenta is delivered following birth of the baby. Pitocin hastens delivery of the placenta and is usually given at this point. Signs of placental separation are: Globular shape and firm uterus Lengthening of the cord
Gush of blood or increase in bloody flow. Stage Three Mechanism of placental delivery are: Schultze Mechanism--80% of the time the shiny fetal surface is seen first. Duncan Mechanism—20% of the time the dull maternal surface escapes first. The placenta will be carefully inspected after delivery For abnormalities For completness Nursing Care During Stage Four Early Post-partum recovery—the first 1-2 hours after delivery. Careful observation and assessment is of utmost importance and may be done every 15 minutes during the first hour. Check B/P, Pulse Fundal tone and location Lochial flow Perineal assessment
Stage Four continued Hemorrhage is the number 1 priority of concern at this time. Pitocin may be use to control P-P bleeding. Warmth is also a need during this period. May be hungry and thirsty. Allow for privacy with family for bonding. Special Situations Precipitate delivery Cerebral trauma for baby Risks for lacerations for Mom Breech presentations Cerebral trauma for baby Longer, more difficult labor for Mom Twin (Multiple) Births Premature births Maternal risks PIH, P-P bleeding nd Delivery of 2 twin often more problems
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