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Childbirth






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Objectives. Use group process to collaborate with peers regarding optimal care for your assigned patient. Explain the effect of the passageway, the passenger, the powers, the position and the psyche on the progress of labor.Describe mechanism of labor and the premonitory signs of labor.Explain the difference between true and false labor..
Childbirth

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1. Childbirth NUR 3450 The University of North Carolina at Pembroke Michelle M. Rupard RNC-OB, MSN, FNP,CLNC

2. Objectives Use group process to collaborate with peers regarding optimal care for your assigned patient. Explain the effect of the passageway, the passenger, the powers, the position and the psyche on the progress of labor. Describe mechanism of labor and the premonitory signs of labor. Explain the difference between true and false labor.

3. Objectives (continued) Discuss nursing interventions appropriate for each stage of labor and delivery. Identify behavioral/physical changes that occur in each labor stage. Acquire a beginning knowledge of electronic fetal monitoring techniques used during the labor process.

4. Factors Affecting Labor & Birth? The Five Ps: Passenger Passageway Powers Positioning Psychologic response

8. What do you see about the passenger in the pictures below?

9. How will you document the fetal position? ROA- Right Occiput AnteriorROA- Right Occiput Anterior

13. Electronic Fetal Monitoring Provides continuous assessment of fetal oxygenation and uterine activity Characteristic patterns signify oxygen status of fetus Includes (2) forms: External fetal monitoring Internal fetal monitoring

14. Electronic Fetal Monitoring External Tocotransducer (?Toco?)-monitors ctx for frequency and length (not strength) Doppler transducer-monitors FHR (Can be interrupted by maternal/fetal movement) Internal-requires ruptured membranes Spiral electrode (aka fetal scalp electrode)-monitors FHR via small wire electrode attached to fetal scalp Intrauterine pressure catheter (?IUPC?)-monitors ctx for frequency, length, AND strength. Can actually CALCULATE and assess for adequate labor.

15. Common EFM terms FHR Baseline: Average FHR over a 10 minute period (excluding accels/decels), normal baseline is 110-160. Variability: Irregular fluctuations seen in FHR, described as: Absent Minimal Moderate Marked

16. Common EFM terms Tachycardia: FHR baseline of 160 or greater (longer than 10 minutes) Nursing interventions Monitor maternal temp O2 Notify provider Bradycardia: FHR baseline of 110 or less (longer than 10 minutes) Nursing Interventions: O2 Notify provider If heart block is diagnosed, no intervention necessary

17. Changes in FHR Periodic Changes Occur with contractions Nonperiodic Changes Also called episodic changes Not associated with contractions

18. Accelerations Increase in FHR of 15 beats or more above baseline x 15 seconds or more (Increase x 10 minutes=change in baseline) Can be periodic or episodic Periodic accels usually seen with breech presentation Episodic accels occur with fetal movement and indicate fetal well-being

19. Decelerations Vary according to: Shape Visual relationship to the contraction onset and ending Classified as: Early Late Variable

20. Early Decelerations Occur with contraction Start before peak and return to baseline as UC ends Indicates head compression Benign finding-no intervention necessary. Associate with vagal nerve stimulation Draw on boardAssociate with vagal nerve stimulation Draw on board

21. Late Decelerations Gradual decrease in FHR Begins after the start of the UC Lowest point is after the UC peak Returns to baseline after UC completion Associated with insufficient placental perfusion, fetal hypoxemia

23. Late Decels?Nursing Interventions O2 at 10 l/min via mask LR bolus Stop Pitocin if infusing Turn pt to lateral position Notify provider of assessment, interventions, outcome Prepare to assist with birth (C/S or vaginal-assisted) if unable to correct

24. Variable Decelerations Abrupt decrease in FHR below baseline Involves decrease of at least 15 beats x 15 seconds, lasting less than 2 minutes. Occur any time in relation to Ucs Caused by cord compression Shape varies, can be U or V shaped

26. Variable Decels? Nursing Interventions Position change (side to side) If persistent or severe: Check cervix, assess for prolapse Stop Pitocin O2 Notify provider of assessment, interventions, outcome Prepare for amnioinfusion if ordered Prepare for birth (C/S or vaginal-assisted)

27. Prolonged Decelerations Decrease in FHR 15 beats or more below baseline x 2-10 minutes. Benign causes: Pelvic exam FSE application Rapid fetal descent Sustained Valsalva maneuver Significant causes: Sudden cord prolapse Maternal hypotension Maternal hypoxia

28. External Fetal Monitoring Noninvasive Used for labor as well as antepartum testing FHR measured via ultrasound transducer Ctx frequency and duration monitored via tocotransducer (?toco?) Repositioning of monitors required prn maternal/fetal position changes

29. Internal Fetal Monitoring FHR monitored via Spiral Fetal Electrode (?FSE? or ?scalp electrode?) Uterine activity monitored via intrauterine pressure catheter (?IUPC?) Requirements: Ruptured membranes Sufficient cervical dilation Presenting part low enough to reach for FSE

30. Reassuring FHR Baseline 110-160 with no decels Moderate variability Accelerations with fetal movement

32. Normal Contraction Pattern Frequency q 2-5 minutes Length less than 90 seconds Intensity moderate to strong Adequate resting tone/time

33. Nonreassuring FHR Associated with fetal hypoxia Can see: Progressive change in baseline (high or low) Tachycardia Decreased or absent variability Severe variables (FHR less than 60 for longer than 30-60 seconds) Late decels Prolonged decel (greater than 60-90 seconds) Severe bradycardia (less than 70 bpm)

34. Other methods of Fetal Assessment.. Scalp stimulation Fetal acoustic stimulation Fetal oxygen saturation monitoring Fetal scalp blood sampling Checking cord gases after delivery

35. Let?s take a short break?

36. Fetal Interventions Tocolysis Administration of tocolytic drug (ie Terbutaline) to relax and treat fetal distress Amnioinfusion Procedure to supplement amniotic fluid or to dilute meconium stained fluid

37. Mechanism of Labor Process of fetal turns and adjustments that lead to a vaginal delivery Involves 7 cardinal movements in a vertex presentation

39. Premonitary Signs of Labor Lightening Urinary frequency Backache Bloody show Braxton Hicks contractions Cervical ripening Possible rupture of membranes

40. ?Is this REAL labor?? Regular UCs progressing in strength, length and frequency More intense with walking Usually felt in lower back, lower abd Continue regardless of comfort measures Cervix Progressive change Becomes anterior Fetus Becomes engaged in the pelvis

41. False Labor Contractions Irregular or only regular for brief period Stop with walking or position change Felt in the back or upper abd Can be stopped with comfort measures Cervix NO significant change May be posterior Fetus Not engaged in pelvis, ?ballottable?

42. Admission Orientation to room, call system, plan of care Pt changes into gown, obtains CCU Electronic Fetal Monitoring initiated Admission data is collected

43. Admission Data includes? Interview Admission form Prenatal record Physical exam Labs, diagnostic test results Significant psychosocial/cultural factors Evaluation of labor

44. Systems Assessment Includes heart, lungs, skin Edema of extremities, face, sacrum DTRs, clonus VS I/O Leopold Maneuvers FHR, UC patterns Vaginal exam

45. Lab, Diagnostic Testing Clean catch urine CBC, T&S Depending on pt history or facility routine: RPR Urine drug screen PIH labs

46. Amniotic Fluid Testing Nitrazine testing for pH Blue-green to deep blue color indicates alkaline pH consistent with amniotic fluid Yellow to olive-green color indicates acidic body fluids Ferning Specimen of fluid is examined under microscope for presence of ?fern? pattern + ferning indicates amniotic fluid

47. First Stage of Labor Begins with the onset of regular contractions Ends with full cervical dilation and effacement Care usually begins with: Onset of regular ctx with increasing frequency, strength and duration Bloody show Spontaneous rupture of membranes (SROM)

48. First Stage Phases 1. Latent phase Up to 3 cm dilation 2. Active Phase 4-7 cm dilation 3. Transition Phase 8-10 cm

49. The patient in latent phase of labor? Mood is happy, excited Mild anxiety Settles into new environment Uses relaxation techniques, breathing May be able to rest or sleep UCs mild to mod q 5-30 min x 30-45 sec

50. Nursing Interventions for Latent Phase Provide encouragement, praise Assist with comfort measures Provide information re: progress, procedures Encourage breathing, relaxation techniques Offer ice, clear liquids as ordered

52. The patient in active labor? Continues using relaxation, breathing techniques, however? Mood is more serious Needs to use more concentration, energy to deal with intensifying UCs (Mod to strong, q 3-5 min x 40-70 sec)

53. Active Labor Interventions Intervene to uphold pt wishes prn (ie visitors, noise level, etc) Provide encouragement re: Breathing, relaxation, coping techniques, frequent position changes Offer pain meds, epidural as ordered Assess for bladder distention Offer oral care, ice, liquids prn

54. Artificial Rupture of Membranes (AROM) Also called amniotomy Performed by provider during vaginal exam Amnihook is used to place hole in amniotic membranes and allow leakage of fluid Done to augment/induce labor or to better assess fetal/ctx status with internal monitors

55. Intrauterine Pressure Catheter

56. Nursing Care During Amniotomy Explain procedure to pt and assure her of no additional discomfort during exam Educate re: probable progression of UC intensity Provide privacy Pad bed well with chux, linen bed protectors Assist provider with exam, amnihook, placement of internal monitors prn

57. Nursing Care During Amniotomy Document AROM Time Fluid: color, odor, consistency of meconium if present Document maternal temp now and at least q 2 hrs Limit vag exams to decrease risk of infection Change linen protectors, chux now and prn Prepare for meconium delivery if + meconium

58. Nursing Interventions for TRANSITION Constant support Encourage panting respirations prn premature urge to push Comfort, relaxation measures as pt allows Remain calm and encouraging, even if pt is not compliant with instructions

59. The patient in TRANSITION Change in mood: easily agitated (if pain is not relieved with epidural) Requires more concentration for breathing techniques May have urge to push (or to have BM) Having strong UCs q 2-3 min x 45-90 sec

60. Community Activity Second Stage of Labor: What do you expect from your patient? What will your nursing care involve?

61. Second Stage of Labor Begins with full cervical dilation (10 cm) and full effacement (100%) Ends with birth Three phases Latent (laboring down process) Descent (active pushing) Transition (presenting part on perineum)

62. Factors Affecting Length of Second Stage Effectiveness of primary and secondary powers Analgesia/anesthesia Maternal physical/emotional status, support Positioning Parity Pelvic adequacy Fetal size, presentation, position

63. Hints your patient is ready to start pushing? Maternal grunting, screaming Reports overwhelming urge to push Fetal head visible at introitus Increased bloody show Decreased ability to listen Reports perineal burning Changes in FHR

64. Nursing Interventions During Second Stage Notify provider Continue comfort measures Limit distractions Assist with position Continually assess FHR and intervene prn Support the partner, instruct in means to assist Prepare instrument table, infant warmer Be prepared for emergency birth and neonatal resuscitation

65. Special considerations? Nuchal cord Following delivery of head, provider gently slips cord over head If loop of cord is too tight (or if nuchal x 2) provider clamps and cuts cord prior to delivery of head **Time is of the essence to prevent fetal hypoxia.

66. Fundal pressure?.Just say ?NO!? Application of pressure against fundus to facilitate vaginal birth Previously used with decreased maternal pushing efforts, shoulder dystocia NO legal or professional standards for this. Increased risk for uterine rupture, fetal injuries Suggest suprapubic pressure, maternal position changes or calling surgical team Communicate with provider professionally, but do not compromise materal/fetal safety.

69. Maternal Birth Trauma Episiotomy Midline Mediolateral Lacerations Perineal (1st, 2nd, 3rd, 4th) Vaginal Urethral Cervical

70. Community Activity Third Stage of Labor: What do you expect from your patient? What will your nursing care involve?

71. Third Stage of Labor Begins with birth Ends with delivery of placenta

72. Nursing Interventions During Third Stage Promote skin to skin contact with infant (if newborn is stable) Assessment, possible resuscitation of newborn Assess maternal VS, bleeding

73. Following delivery of placenta? Administer oxytocic medication as ordered Pitocin 20 units in 1000 cc IV fluid Pitocin 10 units IM Methergine 0.2 mg IM (contraindicated with HTN) Assist provider prn in repair of lacerations, episiotomy Clean perineum with warm water, apply ice pack prn Replace foot of bed Complete newborn assessment and care Promote breastfeeding (prn) and family bonding

74. Congratulations! Deborah and David had a healthy baby boy weighing 7 lb, 10 oz. Thanks for your safe and supportive nursing care!


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