1. Chapter 66 Normal Labor, Delivery, and Postpartum Care

2. EMTALA
What is it?

3. Labor and Delivery Six major factors
Psyche- the mother’s psychological response to labor
Powers- uterine contractions>frequency, duration>90.>Intensity> effacement>Dilation
Passenger-fetus and placenta
Presentation-the first part to enter the pelvic- cephalic, breech and shoulder>station negative above the ischial spines-1, -2
Zero-at the ischial spine=engaged(0)
Positive 1-3

4. Powers
Position-relationship of presenting part to the maternal pelvic inlet
Passage-birth canal, pelvis, cervix pelvic floor and vagina
Cephalopelvic disproportion

5. Labor meds Oxytocin Misoprostol Penicillin G Methylergonovine
Terbutaline sulfate
Betamethasone
Methotrexate
Indomethacin

6. Labor False True Braxton hicks Stop by action No cervical changes
No bloody show
Not engaged
contractions

7. Fetal heart rate 110-160 Variability best indicator of well-being
Moderate +6to 25/min
For internal monitor ruptured membrane – can increase infection –
All pelvic checks _sterile technique

8. FHR Monitoring
VEAL=Name
CHOP =cause
MINE= management

9. The Four Stages of Labor
Series of events during which a woman’s uterus contracts and expels a fetus and completes the birthing process
Stage I: Dilation-latent,active, transitional ROM, - nitrazine paper ph blue-pain management
Stage II: Expulsion-push>prevent hyperventiliation
Stage III: Placental-VS;bleeding; fundus;baby care
Stage IV: Recovery-Hemorrhage priority concern/bonding

10. NCLEX Alert!!!!!!!!!!!!!!
Pharmacologic pain
Procedures
Warnings

11. Intrapartum and Postpartum
Time period during which labor and delivery take place
Postpartum
Follows the intrapartum period
Lasts until the end of the sixth week after the birth

12. Choices in Labor and Birth
Birth attendant
Birth setting
Birth plan
Nurse’s role
Inform the policies of the birth setting and birth attendant, and of the need for flexibility if complications develop.

13. Terminology Relating to Pregnancy and Birth
Nulligravida
Nullipara
Primigravida
Multigravida
Primipara
Multipara

14. The Process of Labor Lie
Position of the fetal spinal cord to that of the woman
Normal lie, transverse lie
Presentation
Cephalic presentation: Vertex presentation, face presentation, brow presentation
Breech presentation
Shoulder presentation

15. The Process of Labor (cont’d)
Station
Descent level of the fetal presenting part into the birth canal
Engagement
Fetal head has moved downward in the birth canal; it can no longer be pushed up and out of the pelvis.
Position
Relationship between the presenting part of the fetus to a designated point on one of four quadrants of the woman’s pelvis

16. Variations of Breech Position
Complete breech: Both legs drawn up, bent at both the hip and the knee
Frank breech: Hips bent, but the knees are extended
Kneeling breech: Either one or both legs are extended at the hip, flexed at the knee
Footling breech: Either one or both legs are extended both at the hip and knee
In all types of breech presentation positions, the sacrum is the assigned point.

17. Question
Is the following statement true or false? If the fetus is in a footling breech position, delivery may be difficult or dangerous.

18. Answer
True In a footling breech position, there is a chance the umbilical cord could prolapse because there is so much empty space within the uterus. This could cut off the blood and oxygen supply to the fetus before it is born.

19. Signs of Approaching Labor
The 4 P’s of labor
Passage, passenger, powers, and psyche
Lightening
Settling of the fetus into the pelvis.
2 to 3 weeks before labor begins in primigravidas; may not occur until labor begins in multigravidas
Braxton-Hicks contractions
Show

20. True Versus False Labor
True labor
Contractions: Timing
Irregularly spaced
Regular, rhythmic
Duration, frequency, and intensity
Variable
Increases and becomes closer and stronger over time
Effect of position or activity change
Contractions lessen
Becomes stronger with ambulation or activity
Location where felt
Primarily in low abdomen
Starts in back, radiate to abdomen
Cervical change and presence of “show”
None
Progressive effacement and dilation, show is usually present

21. Uterine Contractions Each labor contraction has three phases.
Increment: Contraction builds from the resting phase to full strength.
Acme: Contraction is at full intensity.
Decrement: Uterine contraction eases, until the resting state is achieved.
Relaxation
The time between contractions

22. Question
Is the following statement true or false? The nurse should report immediately if the client’s contractions come more often than every 2 minutes or if each contraction lasts 90 seconds or longer, or if any yellow, green, or cloudy amniotic fluid is present.

23. Answer
True This is because there is not enough relaxation time for the fetus to be well oxygenated. This event is rare during normal labor but must be carefully watched for when oxytocin is used for labor augmentation or induction. Normal amniotic fluid is clear and colorless, and has a slightly salty odor. Yellow or green fluid may indicate the fetus has passed meconium (stool) while still in utero. White or cloudy fluid may indicate the presence of pus in response to an infection.

24. Nursing Care During Stage I of Labor
Focuses on frequent monitoring of the woman’s vital signs, contractions, and cervical change, as well as the fetus’ well-being cervix dilates
Admission
Observation and data gathering
Emotional and physical support
Relief of discomfort

25. Nursing Care During Stage 1 of Labor (cont’d)
Assessing fetal well-being
Intermittent auscultation
Electronic fetal monitoring
Evaluation of fetal monitor information
Accelerations
Decelerations
Decreased variability

26. Question
Is the following statement true or false? Late decelerations in fetal heart rate occur anytime during or after contractions.

27. Answer
False Variable decelerations in fetal heart rate occur anytime during or after contractions. They usually indicate umbilical cord compression and can usually be altered by changing the woman’s position or by giving her oxygen. Late decelerations begin late in the contraction, and the fetal heart rate recovery occurs after the contraction is over. Decelerations are related to placental insufficiency and indicate fetal distress. The fetal heart rate should not fall below 100 bpm.

28. Nursing Care During Stage II of Labor
Maternal care
An LPN/LVN or RN will assist in delivery.
Coaching the client
Encourage the woman to push only with contractions and to rest between them.
Episiotomy
Incision in the perineum
Neonatal care

29. Nursing Care During Stage III of Labor
Stage III is short; there may be possibility of hemorrhage.
The nurse records:
Time of placenta delivery, spontaneous delivery or manual removal, side of the placenta presented
Nurse may be instructed to administer oxytocics or to massage the fundus gently to minimize blood loss.
Birth attendant
Examines and cleans the cervix and vagina, episiotomy or lacerations, the vulva and perineum and remove stirrups

30. Nursing Care During Stage IV of Labor
Observations and data gathering
Vital signs, fundus of the uterus and the perineum, lochia, mother’s first voiding after delivery
Maternal and newborn feeding
Encourage mother to drink fluids and to put the newborn to her breast
Transfer from the recovery room
Record delivery and other procedures.
Postpartum care: Client teaching

31. Necessary Documentation for Delivery
Complete information about the type of delivery and procedures used; who was present
Sex and condition of the baby (include Apgar score)
Time of birth and time at which the placenta was expelled and presentation
Condition of the fundus
Any medication administered
If an episiotomy was done, and its type
Condition and vital signs of the mother and measured maternal blood loss

32. Changes in Maternal Anatomy
Involution: Reproductive organs return to their nonpregnant state.
Uterus:
Postpartum period: The uterus should be positioned midline and feel firm to the touch.
Abnormal: Deviation to the side, soft or boggy
Lochia: Normally continues for 3 to 4 weeks—Lochia rubra, Lochia serosa, Lochia alba
Abnormal: Large clots, foul odor

33. Changes in Maternal Anatomy
Cervix constricts and firms during the postpartum period. The vagina regains muscle tone.
Episiotomy and perineum should appear clean, with very slight edema.
Abnormal: Inflammation, redness, and discharge from the episiotomy or lacerations, hematomas, ecchymosis, and edema
Abdominal muscle tone is regained by 6 weeks after delivery.
Breasts: Prepare for the newborn’s nourishment; may engorge

34. Changes in Maternal Anatomy
Bladder: New mothers may have stress incontinence or difficulty voiding.
Abnormal: Voiding in small amounts, residual urine, dysuria, bladder infection, urinary retention
Gastrointestinal system: Mother may be constipated for 1 to 2 weeks following delivery pregnancy and may have problems with hemorrhoids after the birth.
Extremities
Abnormal: Redness, pain, and swelling along the path of a vein—superficial thrombophlebitis

35. Question
Is the following statement true or false? It is important to massage a contracted fundus.

36. Answer
False Never massage a contracted fundus because massage of an already contracted uterus may cause it to invert, which can present an emergency situation. Observe the amount, color, and odor of the lochia.

37. Client Teaching Begins at the time of admission
Breast care, nursing and engorgement
Perineal care, care of the stitches and fundus observation
Involution
Activity, rest, and diet
Fluid intake, voiding
Bathing, ambulation

38. End of Presentation