1. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. THE BIRTH PROCESS CHAPTER 52

2. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. SIGNS OF IMPENDING LABOR Lightening-the descent of the fetus into the pelvis (2 weeks before labor begins) Leg cramps from pressure now on pelvic nerves Urinary frequency from pressure now on the bladder Increased venous stasis from pressure now on the veins, resulting in edema of the lower extremities Braxton Hicks contractions-irregular, intermittent contractions felt by the pregnant woman toward the end of pregnancy May become regular and uncomfortable On assessment, no dilation of cervix “false labor” Cervical changes-34 weeks begins to “mature” “ripen” Softer, spongy “effacement”-thinning and shortening of the cervix Bloody show-cervical secretions, blood tinged mucus & mucous plug Labor begins 24-48 hours after bloody show Rupture of membranes – notify Doctor If engagement has not occurred, there is danger that the umbilical cord will wash out with the amniotic fluid If labor does not begin spontaneously withing12-24 hours, it’s induced to prevent infection Nitrazine paper turns blue to asses amniotic fluid or urine Gastrointestinal disturbance- indigestion, n/v, diarrhea near time of labor and may lose 1-3 lbs Sudden burst of energy-Nesting

3. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. MATERNAL SYSTEMIC RESPONSES TO LABOR Cardiovascular system–cardiac output increases. 400ml of blood squeezed from uterus b/p elevates in first and second stage of labor due to contractions (highest at peak of contraction) Anxiety and pain increase b/p May experience supine hypotensive syndrome Respiratory system–oxygen consumption during labor equals moderate to strenuous exercise. If mom develops hypoxia or acidosis, the fetus may be compromised. Renal system–with engagement, bladder pushed forward and upward. A distended bladder may impede fetal descent Encourage to void, may have decreased sensation

4. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. MATERNAL SYSTEMIC RESPONSES TO LABOR (continued) Gastrointestinal system–peristalsis and absorption decrease. NPO during labor in event of emergent surgery Risk of aspiration with vomitus Lips become dry-may moisten or ice chips Fluid and Electrolyte balance–body temperature increases and client perspires profusely. Hyperventilate-lose fluids Prevent dehydration-IVF given Immune system–white blood count increases. The natural increase makes it difficult to identify infection

5. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. MATERNAL SYSTEMIC RESPONSES TO LABOR (continued) Integumentary system–vagina and perineum have great ability to stretch. Each stretch differently, risk of rupture or tear Musculoskeletal system–relaxation of pelvic joints, may result in backache. Leg cramps Neurological system–endorphins increase pain threshold, sedative effect. Euphoric at beginning of labor, then seriousness and amnesia between contractions in 2 nd & 3 rd stage Pressure on the perineum, by the fetus descending causes physiologic anesthesia in the perineal tissues Pains of labor individual, subjective. Visceral pain-first stage, primarily pelvic structures around vagina 2 nd stage, perineum is stimulus for pain Keep para/multigravida & cultures in mind when assessing pain

6. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. VARIABLES AFFECTING LABOR Four Ps: passage, passenger, powers, and psyche. Passage–bony pelvis, uterus, cervix, vagina, and perineum. Passenger–size of fetus, fetal attitude, lie, presentation, position affect ease of advance through the passage. Molding-the shaping of the fetal head to adapt to the mother’s pelvis during labor Sutures-Major bones of skull joined by thin, fibrous, membrane-covered spaces Fontanelles-Where the sutures meet

7. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Passenger, cont. Fetal Attitude-the relationship of fetal body parts to one another. Ideal-flexion(head flexed onto chest, arms flexed over chest, hips & knees flexed on the abdomen If any part is extended, labor is usually more difficult (extension)

8. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Passenger, con’t. Fetal Lie- relationship of the cephalocaudal (head to foot) axis of the fetus to the cephalocaudal axis of the mother Longitudinal lie-parallel with mom Transverse lie-right angle to mom

9. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Passenger, con’t…. Fetal presentation-determined by the fetal lie and the part of the fetus that enters the pelvis first. Presenting part-part of the fetus in contact with the cervix Cephalic presentations Vertex-with occiput presenting Brow-sinciput presenting Face-face presenting Breech presentations Complete-hips and knees are flexed on the abdomen in an attitude of flexion, with the buttocks as the presenting part Frank-the hips are flexed, but the knees are extended with the buttocks as the presenting part Footling breech-the hips and knees are extended with the foot as the presenting part (may be single footling or double footling) Shoulder presentations Shoulder presentation occurs in a transverse lie Presenting part shoulder, arm, back, abdomen, or side

10. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. VARIABLES AFFECTING LABOR (continued) Powers–primary, the involuntary contractions of uterus; secondary, the voluntary use of abdominal muscles by the mother to push. Uterine contractions-begin at the fundus, spread over the uterus in @ 15 secs. Rhythmic contraction and relaxation Increment-increasing intensity of a contraction Acme-peak Decrement-decreasing intensity Frequency, duration(interval), intensity Should not be longer than 90 secs or less than 60 secs May need to reposition FERGUSON’S REFLEX-spontaneous urge to bear down Psyche–mother’s attitude toward labor and her preparation for labor. Shaped by experiences and expectations

11. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. FIRST STAGE: DILATATION AND EFFACEMENT Begins with onset of regular contractions and ends with cervical dilatation. The enlargement of the cervical opening(os) is complete at 10cm. The longest stage of labor. Divided into three phases: latent, active, and transition.

12. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. LATENT PHASE Ends when cervix is dilated 4 cm. Contractions become more frequent. Start 10-20 minutes apart Move to 5-7 minutes apart The duration of contractions becomes longer. Begins 15-20 seconds Progress to 30-40 seconds Intensity of contractions becomes more moderate. Mother is usually alert and talkative. Relieved that labor has begun Anxious about what is ahead Review preparations and expectations of labor and delivery

13. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ACTIVE PHASE Begins when cervix is dilated 4 cm, ends when the cervix is dilated 8 cm. Contractions occur every 3 to 5 minutes with a duration of 40 to 60 seconds. Moderate Intensity progresses to strong. The client focuses more on breathing techniques in contractions, less talkative. Perceives varying degrees of pain.

14. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. TRANSITION PHASE Begins when cervix is dilated 8 cm, ends when cervix is dilated 10 cm. Contractions occur every 2 to 3 minutes with a duration of 60 to 90 seconds. The intensity of contractions is strong. The client needs to be reminded to focus, relax, and breathe with each contraction. VERY AWARE of increasing intensity of contractions and needs to be reminded to focus, relax and breathe with each contraction. Asks for pain med and states “I can’t take it anymore”

15. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. CHARACTERISTICS OF THE TRANSITION PHASE Restlessness Hyperventilation Bewilderment and anger Difficulty following directions Focus on self Irritability Nausea, vomiting Very warm feeling Perspiration Increasing rectal pressure

16. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. SECOND STAGE: BIRTH OF BABY Begins when cervical dilatation is complete and ends with birth of the baby. Now that cervix is completely dilated, the mother can actively push. Contractions continue Q2-3 mins for 60-90 secs. When the largest diameter of the fetal head is past the vulva, Crowning has occurred and birth is imminent. As the fetus moves through the pelvis and birth canal, several changes in position must occur. This series of movements is collectively called the mechanisms of labor or cardinal movements. An episiotomy (an incision in the perineum) may be performed.

17. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. MECHANISMS OF LABOR Engagement (presenting part of the fetus –usually the head- fully enters the true pelvis) Descent (begins with engagement and continues through each contraction and throughout the labor process) Flexion (fetal head is bent forward as it meets resistance during descent, causing the chin to rest on the sternum. This allows the narrowest part of the head to enter the pelvic outlet) Internal rotation (2 nd stage of labor, head rotates so the occiput is next to the symphysis pubis) Extension (fetal head continues to descend, the occiput pivots under the symphysis pubis and the fetal head becomes unflexed {extended} and pushes upward out of the vagina. The head is born at this time) External rotation (once head emerges, it rotates back to be in normal alignment with the shoulders {restitution}) Expulsion (gentle downward pressure is applied on the baby’s head to allow the anterior shoulder to emerge. Then the baby’s head is gently raised to the posterior shoulder can be delivered. The rest of the baby’s body then slides right out.

18. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. THIRD STAGE: DELIVERY OF PLACENTA Begins with birth of baby and ends with delivery of placenta. Should occur in 30 minutes or less. After birth of the baby, uterus continues to contract, reducing the surface area of the placental attachment-causing it to separate. With separation, bleeding occurs, causing a retroplacental hematoma which facilitates separation process. Signs of separation Globular shape of the uterus Gush of blood from the vagina More of the cord protrudes from the vagina(visible) once occurs, mom is asked to push one more time to expel the placenta Birthing facility disposes of the placenta after delivery. Occasionally, client asks to have placenta to uphold cultural expectations.

19. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. FOURTH STAGE: RECOVERY First 4 hours after the birth. Blood loss is usually between 250 mL and 500 mL. ***nursing moderate decrease in b/p and increase in heart rate Uterus should remain contracted to control bleeding, positioned in the midline of the abdomen, level with the umbilicus. Mother may experience shaking chills in response to the ending of the physical work of labor. Mom may be hungry and thirsty.

20. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ADMISSION OF A CLIENT IN LABOR Different for each person. Obtain a good baseline assessment with items we covered last week in class. Priorities include establishing a nurse/client relationship. Assessing the condition of mother and fetus may be undertaken in a sequential order.

21. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. NURSING PROCESS–ASSESSMENT Subjective data: comfort of mother, her ability to cope, need to urinate, defecate. Objective data: vital signs; FHR; frequency, duration, interval, and intensity of contractions; fetopelvic relationships; condition of membranes; maternal behavior; maternal verbalizations.

22. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. NURSING DIAGNOSES Impaired verbal communication Pain Fatigue Anxiety Fear Deficient knowledge Risk for infection Review your nursing goals and interventions for these diagnoses.

23. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. NURSING DIAGNOSES (continued) Risk for deficient fluid volume Impaired urinary elimination Impaired (fetal) gas exchange Altered tissue perfusion (maternal) Impaired physical mobility Ineffective coping Risk for injury Review your nursing goals and interventions for these diagnoses.

24. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PLANNING/OUTCOME IDENTIFICATION Client: Shows progress through labor. Expresses satisfaction with assistance. Maintains adequate hydration. Voids at least every 2 hours. Actively participates in labor process. Does not experience any injury.

25. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. NURSING INTERVENTIONS Assessment, timing contractions, and listening to FHR regularly Comfort measures Hygiene measures Ambulation and position Food and fluid intake Elimination Review your nursing goals and interventions.

26. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. BREATHING TECHNIQUES Provide adequate oxygenation of mother and fetus. Provide a focus of attention. Decrease pain and anxiety. Increase mental and physical relaxation. Review your nursing goals and interventions.

27. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PHARMACOLOGIC COMFORT MEASURES Systemic medications Client willing and v/s stable Fetus is term, normal movement, FHR 120-160, no late or variable decelerations, no meconium staining Contractions well established and dilated 4-5 cm nullipara, 3-4cm multipara Epidural block-continuous or intermittent Placed epidural space Good pain control, client participates in birth process Disadvantage-maternal hypotension, catheter migration, n/v, pruritis, RESPIRATORY DEPRESSION Intrathecal block-intrathecal inj. Of opioid analgesic Rapid onset, no sedation, no hypotensive effect and no motor block Disadvantage-short duration, may need another injection, inadequate pain relief in late labor and birth Local infiltration-local to perineum Techinically uncomplicated, practically free of complications Disadvantage –large amount of local anesthetic may be needed Pudendal block-local to pudendal nerve to provide perineal, external genitalia, and lower vaginal anethesia No change in maternal, fetal v/s Distadvantage-rectal puncture, sciatic nerve block, hematoma General anesthesia Loss of consciousness, rarely used in vaginal births but may be used for cesarean GREATEST DANGER IS FETAL DEPRESSION (USUALLY REACHES FETUS WITHIN 2 MINUTES)

28. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. RISKS OF LABOR AND BIRTH Preterm labor and birth-between 20-37 weeks Premature rupture of membranes-before labor begins (most common cause of preterm labor) Dystocia-long, difficult or abnormal labor Dysfunctional labor:ineffective contractions or maternal pushing efforts(powers) Pelvic structure variations(passage) Fetal variations: anomalies, abnormal presentation or position, very large size, or number of fetuses (passenger) Mother’s response: related to preparation for childbirth, past experiences, culture, and support persons (psyche) Abnormal duration of labor Prolapsed cord-umbilica cord lies below the presenting part of the fetus ***A cord below the pesenting part is compressed between the fetus and the mother’s pelvis, resulting in decreased blood flow to the fetus. Fetus will be bradycardic and have variable decelerations during uterine contractions EMERGENT***When a prolapsed cord is identified, pressure on the cord must be relieved immediately. The provided must call for assistance, don a sterile glove, insert two fingers into the vagina, and put pressure on the presenting part to relieve the compression of the cord. The client can then be assisted into a modified Sims’ position with her hips up on pillows, the knee-chest position, or place the bed in Trendelenburg position. Gravity keeps the pressure of the presenting part off the cord. Occasionally, a vaginal birth may be possible, but generally a CESAREAN BIRTH is preferred.

29. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. INDUCTION/ AUGMENTATION OF LABOR Induction–stimulation of uterine contractions before they begin spontaneously. Oxytocin(pitocin) & LR, rate is very slow with small increases at regular intervals Goal is to have the contractions 2-3 minutes, duration 40-60 secs, moderate intensity REVIEW SAFETY AND WHEN YOU NEED TO STOP AN OXYTOCIN INFUSION, pg 1511 Augmentation–stimulation of contractions after spontaneously beginning, but with unsatisfactory progress. Oxytocin is used in same manner.

30. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. CESAREAN BIRTH Birth of an infant through an incision in the abdomen and uterus. Scheduled (complete placenta previa, hydocephaly) or unscheduled (some difficulty in labor process). Foley, surgical shave prep, IVF, Blood & urine tests, preop teaching if time allows, consent, support Pediatrician is usually present to care for the infant. Some clients may be able to have a vaginal birth with next pregnancy.

31. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. FORCEPS-ASSISTED BIRTH Forceps are metal instruments used on fetal head to assist in delivery. Outlet-head crowning Low forceps-head is at +2 station or lower but not crowning Midforceps-head is engaged but above +2 station Cervix must be completely dilated and membranes must be ruptured. Position and station of fetal head must be known. Mom exhausted or one who has heart disease and a fetus in distress, in arrested rotation, or breech position Newborn possible facial bruising, edema.

32. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. VACUUM-ASSISTED BIRTH Indications are same as for forceps-assisted birth. A cup connected to suction is placed over the occiput on fetal head, suction(negative pressure) is attained, traction downward and outwards is applied during contractions Maternal risks include vaginal and rectal lacerations. Fetal risks: cephalhematoma, brachial plexus palsy, retinal and intracranial hemorrhage, hyperbilirubinemia.

33. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. CARE OF THE INFANT First 20-30 minutes after infants birth Infection control-gloves until first bath Assess lochia & perineum Cleanse perineum A–airway B–breathing C–circulation W–warmth

34. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. CARE OF THE MOTHER Take blood pressure before and after adminsistration of oxytocic medication. Fundus of uterus should be firm, size of grapefruit, in midline, below umbilicus. Episiotomy is washed and dried. Maternity vaginal pads are applied. Mother and infant are allowed to bond.