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The Process of Labor and Birth
Chapter 12 The Process of Labor and Birth
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Labor and Birth Process—Critical Factors
Powers (physiologic forces) Passageway (maternal pelvis) Passenger (fetus and placenta) Passageway + passenger relationship Psychosocial influences
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Powers Uterine contractions—primary force
Maternal pushing efforts—secondary force Characteristics of uterine contractions Increment Acme Decrement
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Assessment of Uterine Contractions
Characteristics Frequency Duration Intensity Palpation Electronic fetal monitoring Refer to Figure 12-1 for Intensity
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Electronic Fetal Monitoring
External monitor—tocodynamometer Noninvasive Internal monitor—internal pressure catheter Invasive
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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)
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Powers Maternal Pushing Efforts
“Bearing down” sensation Urge to push No urge to push
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Passageway Maternal Pelvis and Soft Tissues
Four classic types Gynecoid—normal female Android—heart shaped, male Anthropoid—apelike Platypelloid—flat oval Refer to Chapter 5
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Passenger Fetus and fetal membranes Molding of head Fetal lie
Longitudinal Transverse Oblique Refer to Box 12-2 for fetal skull landmarks Refer to Figure 12-4 for Fetal Lie
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Passenger (cont.) Fetal attitude—flexion Fetal presentation Cephalic
Vertex Military Brow Face
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Advantages of Cephalic Presentations
Head usually largest part of infant Molding Optimal shape—smooth and round
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Breech Presentations Buttocks enter maternal pelvis first
Frank: legs extended toward shoulders Complete: legs flexed Footling: one or both feet present first into maternal pelvis (SACRUM is landmark) Refer to figure 12-7 for types of breech presentations
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Disadvantages of Breech Presentation
Risk of cord prolapse Presenting part less effective in cervical dilation Risk of cord compression Risk of prolonged labor
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Shoulder Presentation
Occurs when fetus in transverse lie Cannot be delivered vaginally unless rotation occurs Refer to Figure 12-8 for Shoulder presentation
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Passageway + Passenger Relationship
Engagement Station Ischial spines—0 station Above ischial spines—(–) minus station Below ischial spines—(+) plus station +4 cm means that ... Refer to Figure 12-9 for station
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Position Vertex—occiput (O) Face—chin (M = mentum) Breech—sacrum (S)
Shoulder—acromion process (A) Four quadrants of maternal pelvis Refer to Figure for position
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Landmarks Abbreviations are used Examples
First and last letter—maternal pelvis Middle letter—fetus presenting part Examples ROA (right occiput anterior) ROP LSP
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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
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Signs and Symptoms of Impending Labor
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Lightening May cause Leg cramps Increased pelvic pressure
Increased urinary frequency Increased venous stasis Increased vaginal secretions
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Other Signs and Symptoms
Braxton Hicks contractions Cervical changes Bloody show Rupture of membranes Energy spurt Weight loss, GI disturbances
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True and False Labor TRUE labor
Leads to dilation and effacement of cervix Regular contractions Contractions increase in duration, frequency, and intensity Refer to Table 12-1 for differences between True & False Labor
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True and False Labor FALSE labor No cervical changes Contractions
Felt in abdominal region Do not increase in intensity Often stop with activity
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Childbirth Settings and Labor Support
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Admission Procedures Establish positive relationship
Collect admission data Initial admission assessments Focused Psychosocial assessment Cultural assessment Laboratory tests Refer to Table 12-2 for circumstances that warrant going to birthing center
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FIRST STAGE OF LABOR Stage of dilation Three phases Friedman curve
Latent phase—0 to 3 cm Active phase—4 to 7 cm Transition—8 to 10 cm Friedman curve Refer to Table 12-3 for summary of characteristics of first & second stages of labor Refer to figure for normal pattern graph
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Nursing Care Ongoing assessment Facilitate a positive birth experience
Manage discomfort Advocate for patient’s needs Provide anticipatory guidance
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Labor Support Presence Promote comfort Environment Personal hygiene
Elimination Supportive relaxation techniques
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Fetal Assessment Position Fetal heart sounds Baseline FHR Presence of
Variability Accelerations Decelerations Refer to Figure for accelerations Refer to Figure for decelerations
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Interpretation of FHR Tracings
Consider contraction frequency and intensity, stage of labor, and earlier FHR pattern Reassuring Non-reassuring Refer to Box 12-4 for Reassuring v. Non-reassuring
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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
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Second Stage of Labor Full dilation through birth of infant
Urge to push Promote effective pushing Closed-glottis Open-glottis Position of comfort
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Preparation for Birth Bulging of the perineum and rectum
Flattening and thinning of the perineum Increased bloody show Labia begin to separate
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Imminent Birth Crowning Burning sensation Intense pressure in rectum
Episiotomy Midline Mediolateral Refer to Figure for Crowning Refer to Figure for Episiotomy
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Cardinal Movements of Birth
Descent Flexion Internal rotation Extension Refer to Figure 12-23
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Cardinal Movements (cont.)
Restitution External rotation Expulsion
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Birth Animation You may wish to incorporate this animation into your teaching plan. It may be necessary to download QuickTime—Click on Get QuickTime and install the program.
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Umbilical Cord Clamping
Controversy regarding when, how Nurse—inspect cut cord for presence of two arteries and one vein Collect cord blood sample for laboratory analysis Refer to Figure for a Vaginal birth sequence
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Nursing Diagnoses for Intrapartal Patient
Pain Knowledge deficit Anxiety Fatigue Risk for infection Impaired fetal gas exchange
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Third and Fourth Stages of Labor
Immediate care of the newborn Delivery of the placenta Monitoring and assisting mother with physiological adjustments following birth Facilitating maternal-infant attachment Refer to Table 12-6 for Characteristics of 3rd & 4th Stages of Labor
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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 Refer to Figure for Schultze & Duncan Manner
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Separation and Expulsion of the Placenta
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Nursing Care—Third Stage
Observe for signs that placenta has separated Oxytocic medications to control blood loss Examine cotyledons Offer emotional support Foster infant attachment Refer to Figure 12-6 for Cotyledons
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Immediate Care of Newborn
Airway Warmth Appraisal—Apgar score Identification of newborn Refer to Table 12-7 for APGAR
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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
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FOURTH STAGE Assess lochia Vital signs and urine output
Shivering—offer blankets Promote comfort Facilitate attachment and breastfeeding
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Fourth Stage—Risk Signs
Hypotension Tachycardia Excessive bleeding Noncontracting uterus
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Promoting Patient Comfort During Labor and Birth
Chapter 13 Promoting Patient Comfort During Labor and Birth
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Pain During Labor and Birth
Shaped by past experiences Assessing pain Physiological, psychological indicators Patient responses May be intensified by fear, anxiety, fatigue
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Physical Causes of Pain
Labor and Birth
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Pain Neurology Uterine ischemia Visceral pain—dull and aching
Referred pain Somatic pain—sharp, burning, prickling
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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
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Factors Affecting Maternal Pain Response
Physical Physiological Psychological Anxiety, fear, previous experience Support systems, childbirth preparation Environmental
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Pain Pathways and Childbirth
Multidimensional phenomenon Affective, physiologic, behavioral, sensory, cognitive Neural pathway for pain Gate-control theory
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Benefits of Comfort and Support
Pain Perception
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Nonpharmacological Pain Relief Measures
Maternal position and movement Breathing techniques Music Relaxation techniques Other attention-focusing strategies Guided imagery
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Massage and Touch Effleurage Counterpressure Therapeutic touch
Healing touch
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Other Therapies for Comfort
Hydrotherapy, hypnotherapy, aromatherapy Application of heat and cold Biofeedback, TENS, intradermal water block Acupressure/acupuncture
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Pharmacological Pain Relief Measures
Timing Nonpharmacological and pharmacological measures promote positive experience Informed consent
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Pharmacological Measures
Sedatives and antiemetics Barbiturates Benzodiazepines H1-Receptor antagonists
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Analgesics and Anesthetics
Systemic Opiod agonist analgesics Opiod agonist-antagonist analgesics Opiod antagonists Refer to Boxes 13-1 & 13-2 for analgesic/anesthetic selection based on stage of labor Refer to Table 13-2 for Commonly used regional blocks
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Nerve Block Analgesia, Anesthesia
Regional anesthesia Local perineal infiltration anesthesia Pudendal nerve block Spinal anesthesia block Complications: maternal hypotension, decreased placental perfusion, ineffective breathing pattern
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Postdural Puncture Headache
Leakage of cerebrospinal fluid Intensified in upright position Auditory and visual problems Autologous epidural blood patch Discharge instructions
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Epidural Anesthesia or Analgesia Block
Local anesthetic—epidural space Pain relief from contractions Pain relief from birth Opioid and local anesthetic agent
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Lumbar Epidural Advantages Complication Minimal trauma to fetal skull
No fetal respiratory depression Complication Maternal hypotension
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Maternal Hypotension Prevention Requires constant nursing attendance
Preload IV fluids Requires constant nursing attendance Monitor vital signs
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Disadvantages of Epidural
Limited mobility Common side effects Accidental injection into blood vessel Sympathetic blockage Urinary retention, bladder distention
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Other Nerve Blocks Combined spinal-epidural analgesia
Epidural and intrathecal opioids Ongoing nursing assessments essential
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General Anesthesia Major risks Pre-operative preparation
Cricoid pressure Anesthetic gases and medications Recovery room nursing care Refer to Box 13-3 for obstetric complications requiring surgical intervention
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Nursing Care Related to Comfort Measures
Assessment Ongoing and collaborative Diagnoses Anxiety Ineffective coping Acute pain
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Nursing Care Expected outcomes Plan of care Individualized
Modified as needed Collaborative approach
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Caring for the Woman Experiencing Complications During Labor and Birth
Chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth Refer to Box 14-1 for possible nursing diagnoses
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Dystocia Long, difficult, or abnormal labor May arise from Powers
Passenger Passageway Refer to Box 14-2 for Dystocia
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Dysfunctional Labor Pattern: Hypertonic
Strong, painful, ineffective contractions Contributing factor—maternal anxiety Occiput-posterior malposition of fetus Management Rest, hydration, sedation Facilitate rotation of the fetal head Refer to Figure 14-1 for Hypertonic & Hypotonic
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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
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Precipitate Labor and Birth
Rapid intense contractions Nursing considerations 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
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Pelvic Structure Alterations
Pelvic dystocia Soft tissue dystocia Trial of labor To assess safety of vaginal birth
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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
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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
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Induction of Labor Indications for induction Bishop score
Cervical ripening agents Mechanical methods Oxytocin Augmentation of labor Refer to Table 14-1 for Bishop scoring system
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Induction—Nursing Considerations
Informed consent Careful monitoring of labor Discuss pain relief measures Position changes Keep patient and support person informed of progress
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Instrumentation Assistance of Birth
Forceps Vacuum extraction Refer to Figure 14-3 for forceps Refer to Figure 14-4 for vacuum extraction
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Maternal Complications—Hypertensive Disorders
Preeclampsia-eclampsia, HELLP syndrome Nursing Careful assessments Monitor lab values Administer platelets as appropriate Ongoing education Refer to Box 14-3 for fetal-maternal factors that necessitate immediate interventions Refer to Box 14-4 for Key parameters to be monitored
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Maternal Complications—Diabetes
Fetal lung maturity Intrapartum management—maternal hydration and blood glucose levels Labor: normal progression of labor Upright or side-lying position Encourage breastfeeding
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Preterm Labor and Birth
Careful maternal monitoring FHR monitoring *** Identify and report symptoms suggestive of fetal hypoxia Assess psychological status
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Labor and Birth Complications—Fetal
Fetal malpresentation Version: external or internal Shoulder dystocia Cephalopelvic disproportion Multiple gestation Non-reassuring FHR patterns Refer to Figure 14-6 for Version Refer to Figure 14-7 for McRoberts maneuver
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Amniotic Fluid Complications
Oligohydramnios Hydramnios Meconium Nuchal cord
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Complications—Placental Problems
Placenta previa Placental abruption Disseminated intravascular coagulation Refer to Table 14-3 for nursing care of patient experiencing intrapartal hemorrhage
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Other Complications Uterine rupture Uterine inversion
Obstetric emergency Uterine inversion Umbilical cord prolapse
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Variations—Umbilical Cord and Placenta
Velamentous cord insertion Fetal vessels separate at distal end and insert into placenta away from the margin Vasa previa Fetal vessels cover cervical os Refer to Figure 14-11
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Placental Variations Circumvallate placenta Succenturiate placenta
Battledore placenta Placenta accreta Placenta increta Placenta percreta
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Amniotic Fluid Embolism
Rapidly deteriorating maternal condition Acute dyspnea, severe hypotension Rapid delivery after stabilizing mother Ethical conflict Save mother versus fetus
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Collaboration in Perinatal Emergencies
Refer to Box 14-5 for team expectation in obstetric emergency
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Perinatal Fetal Loss Nursing considerations What to say
What not to say
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Cesarean Birth Indications Ethical considerations Surgical procedures
Health of mother or fetus is jeopardized Ethical considerations Surgical procedures Surgical and postoperative care Vaginal birth after cesarean
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Postterm/Prolonged Pregnancy
Postterm—extends beyond 42 weeks Risk for fetal/neonatal problems Increased maternal risk Management—labor induction Nursing implications
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