1. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Chapter 12 The Process of Labor and Birth Edited by Catherine Marin, MSN/Ed(c), WHCNP, RN

2. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Labor and Birth Process— Critical Factors  Powers (physiologic forces)  Passageway (maternal pelvis)  Passenger (fetus and placenta)  Passageway + passenger relationship  Psychosocial influences

3. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Powers  Uterine contractions—primary force  Maternal pushing efforts—secondary force  Characteristics of uterine contractions  Increment  Acme  Decrement

4. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Assessment of Uterine Contractions  Characteristics  Frequency  Duration  Intensity  Palpation  Electronic fetal monitoring

5. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Electronic Fetal Monitoring  External monitor—tocodynamometer  Noninvasive  Internal monitor—internal pressure catheter  Invasive

6. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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)

7. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Powers Maternal Pushing Efforts  “Bearing down” sensation  Urge to push  No urge to push

8. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Passageway Maternal Pelvis and Soft Tissues  Four classic types  Gynecoid—normal female  Android—heart shaped, male  Anthropoid—apelike  Platypelloid—flat oval

9. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Passenger  Fetus and fetal membranes  Molding of head  Fetal lie  Longitudinal  Transverse  Oblique

10. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Passenger (cont.)  Fetal attitude—flexion  Fetal presentation  Cephalic  Vertex  Military  Brow  Face

11. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Advantages of Cephalic Presentations  Head usually largest part of infant  Molding  Optimal shape—smooth and round

12. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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)

13. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Disadvantages of Breech Presentation  Risk of cord prolapse  Presenting part less effective in cervical dilation  Risk of cord compression  Risk of prolonged labor

14. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Shoulder Presentation  Occurs when fetus in transverse lie  Cannot be delivered vaginally unless rotation occurs

15. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Passageway + Passenger Relationship  Engagement  Station  Ischial spines—0 station  Above ischial spines—(–) minus station  Below ischial spines—(+) plus station  +4 cm means that...

16. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Position  Vertex—occiput (O)  Face—chin (M = mentum)  Breech—sacrum (S)  Shoulder—acromion process (A)  Four quadrants of maternal pelvis

17. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Landmarks  Abbreviations are used  First and last letter—maternal pelvis  Middle letter—fetus presenting part  Examples  ROA (right occiput anterior)  ROP  LSP

18. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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

19. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Signs and Symptoms of Impending Labor

20. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Lightening  May cause  Leg cramps  Increased pelvic pressure  Increased urinary frequency  Increased venous stasis  Increased vaginal secretions

21. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Other Signs and Symptoms  Braxton Hicks contractions  Cervical changes-true labor  Bloody show  Rupture of membranes  Energy spurt  Weight loss, GI disturbances

22. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley True and False Labor  TRUE labor  Leads to dilation and effacement of cervix  Regular contractions  Contractions increase in duration, frequency, and intensity

23. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley True and False Labor  FALSE labor  No cervical changes  Contractions  Felt in abdominal region  Do not increase in intensity  Often stop with activity

24. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Childbirth Settings and Labor Support

25. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Admission Procedures  Establish positive relationship  Collect admission data  Initial admission assessments  Focused  Psychosocial assessment  Cultural assessment  Laboratory tests

26. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley FIRST STAGE OF LABOR  Stage of dilation  Three phases  Latent phase—0 to 3 cm  Active phase—4 to 7 cm  Transition—8 to 10 cm  Friedman curve

27. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Nursing Care  Ongoing assessment  Facilitate a positive birth experience  Manage discomfort  Advocate for patient’s needs  Provide anticipatory guidance

28. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Labor Support  Presence  Promote comfort  Environment  Personal hygiene  Elimination  Supportive relaxation techniques

29. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Fetal Assessment  Position  Fetal heart sounds  Baseline FHR  Presence of  Variability  Accelerations  Decelerations

30. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Interpretation of FHR Tracings  Consider contraction frequency and intensity, stage of labor, and earlier FHR pattern  Reassuring  Non-reassuring

31. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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

32. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Second Stage of Labor  Full dilation through birth of infant  Urge to push  Promote effective pushing  Closed-glottis  Open-glottis  Position of comfort

33. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Preparation for Birth  Bulging of the perineum and rectum  Flattening and thinning of the perineum  Increased bloody show  Labia begin to separate

34. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Imminent Birth  Crowning  Burning sensation  Intense pressure in rectum  Episiotomy  Midline  Mediolateral

35. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Cardinal Movements of Birth  Descent  Flexion  Internal rotation  Extension

36. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Cardinal Movements (cont.)  Restitution  External rotation  Expulsion

37. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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

38. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Nursing Diagnoses for Intrapartal Patient  Pain  Knowledge deficit  Anxiety  Fatigue  Risk for infection  Impaired fetal gas exchange

39. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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

40. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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

41. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Separation and Expulsion of the Placenta

42. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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

43. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Immediate Care of Newborn  Airway  Warmth  Appraisal—Apgar score  Identification of newborn

44. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley 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

45. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley FOURTH STAGE  Assess lochia  Vital signs and urine output  Shivering—offer blankets  Promote comfort  Facilitate attachment and breastfeeding

46. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Susan Ward Shelton Hisley Fourth Stage—Risk Signs  Hypotension  Tachycardia  Excessive bleeding  Noncontracting uterus