PROCESS OF NORMAL LABOR

PROCESS OF NORMAL LABOR
CHAPTER 7

Events Before Onset of Labor
nUnknown what actually starts labor
nLightening: “baby drops down”, baby settles in maternal pelvis
nVaginal discharge or bloody show: pink stained mucus
nEnergy spurt or nesting time
nFalse labor: no cervical dilatation
nSpontaneous rupture of membranes or SROM
nCervical changes – effacement & dilatation
nsee Figures 7-1,Table 7-1

Major Variables in the Birth Process: The 4 P’s

nPELVIS--size and shape of the pelvis

nPASSENGER- fetus size and position

nPOWERS-effectiveness of contractions

nPSYCHE-preparation, previous experience


PELVIS
nMust be adequate proportions in order for the fetal head to fit through
nAngles are downward, forward, & upward somewhat like the letter “J”

PASSENGER
nFetal Head – must be able to stand extreme pressure
nFetal Bony Skull – bones thin, very elastic, allows for molding

Fetopelvic Relationship

nTerminology:
•Attitude, fig 7-3
• Lie – relationship of the longitudinal axis of the fetus to the mother, should be parallel, not crosswise
•Presentation, body part lowest in mother’s pelvis, fig 7-4
•Position, more specific description of the relationship of the fetal presenting part to the maternal pelvis, fig 7-4
•Station – fig 7-5, -5 to +5, ischial spines used, hardest to determine during a vaginal exam


POWERS-UTERINE CONTRACTIONS

nInvoluntary
nIntermittent but regular
nExhibit a wavelike pattern in 3 phases:
ØIncrement, building up
ØAcme, peak
ØDecrement, decreasing intensity
nAffected by maternal position
Ø supine, more freq, lower intensity
Ø side lying, less freq, more effective

Assessment of Uterine Contractionsfig 7-6

nFrequency: amount of time between the beginning of one contraction to the beginning of the next
nDuration: time between the onset of the contraction & it’s end
nIntensity: strength of the contraction, rough estimate made by palpation;
Ø mild – easy to indent, like touching tip of nose
Ø moderate – harder to indent but still able to; touching the chin
Ø strong – fundus is very firm & difficult to indent, like touching the forehead
PSYCHE--Psychological and Cultural factors that affect labor
nAnxiety and fear can decrease ability to cope, previous poor experience can effect present experience negatively
nCulture, ethnic background may play a strong role in the way a woman perceives labor and her reaction to it
nMaternal/newborn bonding very important!

MECHANISMS OF LABOR (cardinal movements)

nFigure 7-7
nEngagement and decent
nFlexion
nInternal rotation
nExtension
nCrowning
nExternal rotation
nDelivery of anterior shoulder
nDelivery of posterior shoulder & expulsion

Placental expulsion

n5-30 min after delivery s/s: lengthening of cord--change in shape of uterus-trickle or gush of vaginal blood
nDull- maternal side --Duncan’s mechanism or Dirty Duncan—usually implanted low in uterus
nShiny- fetal side- Schultz’s mechanism or Shiny Schultz—usually implanted high in uterus

FOUR STAGES OF LABOR

n1ST STAGE – begins with the onset of regular contractions until the cervix is fully dilated to 10cm
n2nd STAGE – begins when cervix is fully dilated & ends with birth of the infant
n3rd STAGE – begins with birth of the baby & ends with expulsion of the placenta
n4th STAGE – from placental expulsion to the end of the recovery stage – usually 1-4 hours

Phases of 1st STAGE OF LABOR-

nLATENT PHASE-EARLY STAGE 0-4CM – EARLY, SLOW PART
nACTIVE PHASE-MID PHASE 4CM-7CM – STRONGER CONTRACTIONS
nTRANSITION PHASE-- LAST PART 8CM-10CM-CONTRACTIONS STRONGER, MORE FREQUENT LASTING 60-90 SECS & WOMAN BECOMES IRRITABLE, ANXIOUS, SELF FOCUSED !!!!!


Second Stage of Labor

nExpulsion stage cervix 10 cm
nCoach-- do not hold breath more than 5 secs when pushing
ncrowning of fetal head—seen in external opening of vagina—recedes after contractions
nSecond stage lasts from a few minutes to 2 hours
nepisiotomy- midline or mediolateral
nsupport fetal head and check position of umbilical cord= nuchal cord
nBirth= relief for laboring woman

Third and Fourth Stage

nThird stage-

nBegins with birth to expulsion of placenta lasts up to 30 minutes
nOxytocin (Pitocin) given to keep uterus firm and lessen blood loss after delivery of placenta

nFourth stage-

nRecovery phase after delivery of placenta through first 1-4 hours or until VS stable. 250-500 ml blood loss. CRITICAL--Observe for excessive bleeding! Teach fundal massage.

Physiologic Changes in Laborsee table 7-2

nCardiovascular- increase in b/p, supine hypotension, increased pulse rate
nRespiratory- 02 demand equal to strenous exercise, hyperventilation—encourage to relax between contractions
nRenal--proteinuria, due to muscle breakdown; distended bladder, due to pressure
nGI--peristalsis and absorption decrease--NPO except ice chips, hydration by IV

Assessment of Fetal Health

Assessment of Fetal Health

Prenatal Fetal Assessment
•Why do antepartum testing?

To see if the fetus is okay.


Prenatal Fetal Assessment – table 6-1
• Diagnostic techniques and nursing considerations
§ Diagnostic (obstetric) ultrasound
§ Doppler ultrasound blood flow
§ Chorionic villi sampling
§ Amniocentesis
§ Percutaneous cord blood sampling
§ Nonstress test (NST)
§ Contraction stress test (CST)
§ Biophysical profile (BPP)
§ Vibroacoustic stimulation test
• Psychologic reactions to diagnostic testing – may produce fear & anxiety; allow time for questions & discussion

Fetal Assessment During Labor
• Fetal monitoring during labor is used to identify the healthy fetus vs the fetus showing signs of compromise; measures the response of the FHR to uterine contractions
• Intermittent FHR monitoring
Ø used for low risk pregnancies/labors see box 6-2
Ø uses a doppler or fetal monitor
Ø advantages: places fewer restrictions on maternal activity
Ø some health care providers feel legally vulnerable doing intermittent auscultation; there is a tendency to monitor FHR continuously

•Continuous electronic fetal monitoring
Ø can detect changes & problems immediately & intervene; there is a higher incidence of C-sections due to problems found
Ø data is transcribed on a continuous strip of graph paper or recorded in the computer-fig 6-5
•The nurse’s role
Ø reassuring heart rate pattern reflects adequate oxygenation
Ø nonreassuring heart rate pattern indicate presence of fetal distress,& appropriate nursing measures should be taken – fast focus 6-2
Ø documentation of interventions done on the strip as well as the medical record



Fetal Assessment During Labor
•Types of electronic monitoring
§External – skill 6-2, fast focus 6-3, fig 6-8
§Internal – fig 6-9, fast focus 6-4
•Relation of FHR to uterine contractions during labor: periodic changes – fig 6-10
Ø accelerations
Ø decelerations ( early & late)
Ø variable decelerations

Reassuring and Nonreassuring FHR Patterns – table 6-2

• Normal pattern /reassuring pattern– heart rate of 110-160 beats/min; beat to beat variability is between 6 – 25 beats/min, no decelerations
• Accelerations – brief, temporary increases in FHR of at least 15 beats/min above the baseline; sign of fetal well being
• Decelerations – transitory decreases in FHR from the baseline; labeled in relation to uterine contractions
§ Early
§ Late
§ Variable

EARLY DECELERATIONS
•Fig 6-10, A
•Slowing of FHR when contraction begins; returns to normal at the end of contraction
•Mirrors contraction
•Caused by head compression during contraction; vaginal exam; or fundal pressure
•No intervention required

Late Deceleration
•Fig 6-10, C
•Slowing of FHR after the contraction begins, when uterine blood flow is at a minimum; recover to normal is delayed, until uterine blood flow has resumed
•Causes: utero-placental insufficiency; inadequate fetal oxygenation; maternal HTN
•Interventions: change to side lying position, start O2 10L/min by MASK; correct hypotension if possible; discontinue oxytocin infusion; notify MD
Variable Decelerations
•Fig 6-10, B
•An abrupt, transient drop in FHR before, during, or after uterine contraction related to brief compression of the umbilical cord
•Causes: cord compression, short cord, prolapsed cord, cord around neck, oligohydramnios
•Intervention: Change maternal position, apply 02 if FHR does not respond, correct hypotension if possible, notify MD if measures do not work, amnioinfusioin

FETAL PULSE OXIMETRY
•A transcervical catheter placed against the fetal cheek; level should be between 40 – 70%
•Anything less than 30% may indicate fetal acidosis & require rapid delivery of fetus
•Amniotic membranes must be ruptured & cervix dilated to at least 2 cm

Amnioinfusion

• Intrauterine infusion of warm normal saline or Ringer’s lactate after ROM
• To decrease cord compression; increase fluid if oligohydramnios present; dilute intrauterine meconium; lessen risk of meconium aspiration
• Contraindicated with prolapsed cord, vaginal bleeding, severe fetal distress
• Must use an infusion pump for accurate administration
• Underpads used to absorb extra drainage

Health Care During Pregnancy

Health Care During Pregnancy

Preconception Care

• Health care and screening before pregnancy to identify medical risk factors and/or lifestyle behaviors that can be managed before conception
Goals of Prenatal Care
• Promote good health habits and reduce risk factors to ensure a safe birth for mother and child
• Teach health habits that may be continued after pregnancy
• Educate for self-care during pregnancy
• Provide physical assessment and care
• Prepare parents for parenthood

Cultural Competence

• Awareness and acceptance of and respect for beliefs, values, traditions, and practices different from one’s own
• The ability to adapt health care so that it does not violate the culture or religion of the patient and her family
• Avoid “cultural stereotyping

Prenatal Visits

• Initial health and social history
 personal information; social hx
 medical hx of client & family
 past obstetrical hx

• Physical examination
 head to toe of all body systems
 wt, ht, v/s; urine
 pelvic examination; have the woman empty her bladder prior

Prenatal Visits

Subsequent visits

Every month for 7 months, every 2 weeks during 8th month, then every week until delivery
Weight, blood pressure, urine (protein, acetone, and glucose)
Uterine height measurement for fetal growth
•
 Every month for 7 months, every 2 weeks during 8th month, then every week until delivery
 Weight, blood pressure, urine (protein, acetone, and glucose)
 Uterine height measurement for fetal growth
 Leopold’s maneuvers to assess presentation and position of fetus
 Listen to fetal heart rate
 Assess for CVA and calf tenderness
 Identify discomforts and suggest nursing or medical relief measures
 Discuss birth plans and infant feeding

Patient Teaching for Self-Care and Common Discomforts of Pregnancy

Douching – do not douch during pregnancy
Clothing – wear adjustable, loose, washable, and lightweight clothing. Do not wear knee highs, tight garters or high heeled shoes once the center of gravity starts to shift
Breast and nipple care – wear supportive bra; do not apply soap to nipples during bathing because it causes a drying effect; breasts may secrete colostrum, a yellow fluid, before or during the last trimester; may need to wear pads inside bra

Bathing

 avoid hot tubs or saunas because they increase body temperature which may cause fetal abnormalities
• Physical activity and exercise
 Special considerations: mild to moderate exercise is good; she should not lie supine, twist, bounce, or make jerky movements during exercise, box 5-1
 helpful exercises: pelvic tilt-fig 5-6 & Kegel exercise-box 5-2
 avoid supine hypotensive syndrome

• Sexual activity

 should not have to be restricted except if the bag of waters has ruptured or after labor begins
• Douching – do not douch during pregnancy
• Clothing – wear adjustable, loose, washable, and lightweight clothing. Do not wear knee highs, tight garters or high heeled shoes once the center of gravity starts to shift
• Breast and nipple care – wear supportive bra; do not apply soap to nipples during bathing because it causes a drying effect; breasts may secrete colostrum, a yellow fluid, before or during the last trimester; may need to wear pads inside bra

• Dental care – continue routine care except avoid xrays

• Immunizations

 Avoid MMR and varicella (potential fetal damage)
• Employment – no heavy lifting or exposure to harmful substances
• Travel – maximum of 6 hours per day driving; stop every 2 hrs for 10 minutes to walk around
• Medications
 No medications unless prescribed by health care provider (includes OTCs and herbal remedies)
Danger signs
 Provide information on reportable danger signs, written at an appropriate level and in a language she can read – fast focus 5-2
• Weight gain and fetal growth
 25 to 35 lb total--with 3 lb in 1st trimester, then 1 lb per week
 Dieting is not recommended—may limit fetal growth

Nutrition
• Obtain nutritional history of food habits and preferences, monitor nutritional status, and provide nutritional education
• Food guide pyramid
• Nutritional requirements during pregnancy – table 5-3
• Pica: eating substances usually considered inedible, with no nutritional value
• Pregnant adolescent

Education for Childbirth

• Principles
 Partner participation and support
 Relaxation and breathing strategies
 Muscle conditioning
 Knowledge of choices and alternatives
• Breathing patterns used during labor
 First-stage
• Slow-paced
• Modified-paced
• Patterned-paced

• Breathing patterns used during labor
 Second-stage (expulsion breathing)
• Open-glottis technique-pushing as if blowing out a candle
• Closed-glottis technique-not recommended because it decreases blood flow to fetus; if done do not hold breath for more than 6 sec

Psychologic Changes During Pregnancy lecture notes

Physiologic and Psychologic Changes
During Pregnancy

• Profile of previous pregnancy history –
§ GTPALM
§ PG – we will use this one mostly
§ P: para (number of births after 20 weeks gestation)
§ G: gravida (total number of pregnancies, including current pregnancy)
§ T: Term births
§ P: Preterm births
§ A: Abortions
§ L: living children

Prenatal Care

Determination of date of birth

Nägele’s rule –

Wheel – see example

Duration of pregnancy

280 days using 28-day months is called lunar months; 10 lunar months; 40
weeks

9 calendar months; Divided into 3 trimesters

Abortion/miscarriage – a pregnancy that terminates before the fetus
reaches 20 weeks gestation

Preterm/premature – a pregnancy that terminates after the 20^th
week of gestation, but before full term

Prenatal Care

Signs of pregnancy

Presumptive – (may suggest pregnancy)

Probable – (strongly indicates pregnancy)

Positive – (confirms pregnancy)

fetal heart tones are heard

fetal movement is palpated by the examiner

fetal outline is visualized by ultrasound

Physiologic Changes in Body Systems

• Endocrine System
• increase in hormones
• addition of the placenta during pregnancy; producing large amounts of estrogen & progesterone

Reproductive system

Uterus- prepregnancy wt – 60g or 2 oz

postpregnancy wt – 1000g or 2.2 lbs

Cervix – becomes shorter & softer

Ovaries – follicles cease to develop to maturity Ovulation does not
occur; produces the hormone relaxin

Vagina- walls become thicker, pliable & expandable in preparation for the
tremendous stretching necessary for the birth; increased vaginal discharge

Breasts – preparation for lactation; size increases; breasts become full,
sensitive, & tender; darkening of the areola & nipple; Montgomery’s glands
become more prominent & lubricate & protect nipple in preparation for
breastfeeding

Physiologic Changes in Body Systems

Musculoskeletal system – relaxation of joints and adjustments in posture

joints relax & symphysis pubis widens as result of relaxin & progesterone

as the uterus enlarges, the center of gravity shifts forward causing
lordosis

abdominal muscles may separate causing diastasis recti abdominis

may develop carpal tunnel syndrome due to compression of the medial nerve
around the wrist

Cardiovascular system –

• Respiratory system – thoracic circumference increases; 02 consumption increases by 15%
§ Dyspnea – caused by a greater sensitivity of the respiratory system & pressure of the uterus on the diaphragm
§ Epistaxis – caused by increased vascularity due to increased estrogen; deepening of the voice
• Gastrointestinal system
gum hypertrophy
increased saliva production
nausea with or without vomiting during 1st trimester
increased heartburn
delayed emptying of intestines leading to constipation
altered CHO metabolism; gestational diabetes

Physiologic Changes in Body Systems

Renal system

frequent urination

urine stasis

more prone to developing pyelonephritis (infection of the upper urinary
tract)

Integumentary system

hyperpigmentation of skin

on the face; chloasma; mask of pregnancy

linea nigra dark line on the abdomen – fig 4-5

striae gravidarum or stretch marks

Psychologic Changes During Pregnancy

• Body image may change
appearance; may begin to feel ugly or fat; negative about pregnancy
function; losing control of body; urine incontinence
sensation may become more acute; change in sexuality & libido mobility may be a problem

Developmental tasks

Pregnancy validation – 1^st trimester; focus on nurturing &
protecting the fetus; questioning identity as a woman & mother

Fetal embodiment – 2^nd trimester; attempts to incorporate the
fetus into her body image as part of self

Fetal distinction – feels quickening or fetal movement; the fetus becomes
separate from her – fig 4-7

Role transition – 3^rd trimester; psychologically separates
self from fetus & makes concrete plans for the baby

Psychologic Changes During Pregnancy

Responses to pregnancy

partners’ response; announcement, adjustment, focus

older couple

adolescent

single

grandparents

siblings

Fetal Development

Fetal Development

Genetics

CHROMOSOMES

• Threadlike, spiral structures found in the nucleus of the cell
• Each cell in the human body contains 46 chromosomes
• Two types of cell division:

 mitosis – the exact duplication of the DNA content in the nucleus of the cell. Produces two identical cells
 meiosis - occurs in the sex cells; cells undergo 2 sequential divisions whereby the number of chromosomes is 1st reduced by half so that chromosomes are inherited from both the mother and father; and then continue with regular cell division or duplication

GENES
• In each gene, a segment of the DNA chain, is coded for inherited traits
• Genes carry instructions for dominant & recessive traits
• Only 1 dominant gene is needed to express the trait
• If only 1 parent has a dominant gene for a trait there is a 50% chance that each child will have the trait

SEX DETERMINATION
• Determined at fertilization
• Sperm contain both an x and a y chromosome
• Eggs only contain x chromosomes
• If the sperm donates an x chromosome the baby will be a girl = xx
• If the sperm donates a y chromosome the baby will be a boy = xy

Embryonic Development

FETAL DEVELOPMENT
• Implantation – usually occurs in the upper segment of the uterus
 after implantation teratogenic agents may be very damaging to the developing embryo
• Embryonic cell differentiation
• Fetal membranes and amniotic fluid
 2 membranes begin to form at the time of implantation: amnion which is the inner layer & the chorion is the outer layer
 later they fuse to form the amniotic sac or bag of waters
 normal volume of amniotic fluid is 800-1000ml. If > 2 liters is termed hyramnios & is associated with malformations of the fetal CNS & GI tracts


PLACENTA
• permits the exchange of materials between fetus & mother – fully formed is a flat disk about 1” thick & weighs 500 grams
o Functions:
 Placental transfer: movement of gases, nutrients, waste materials, drugs & other substances across the placenta from maternal to fetal circulation & back
 Immunologic functions: protection of the fetus from some pathogens & prevention of rejection by the mother
 Blood flow: can be reduced if uterine artery is constricted due to HTN, during strong contractions or when mother is in supine position
 Endocrine functions: production of hCG for maintenance of pregnancy; hPL which produces changes in the mother’s metabolic processes; progesterone to maintain the thick lining of the uterus & development of the breasts for lactation.

Embryonic Development

FETAL CIRCULATION –
• Fetus receives oxygen from the mother via the placenta so lungs do not perform this function in utero
• Ductus arteriosus – connects the pulmonary artery with the aorta, bypassing the lungs
• Ductus venosus – bypasses the liver
• Foramen ovale – located between the two atria of the heart; bypasses the right ventricle which would send blood to the lungs

CIRCULATION AFTER BIRTH

• Clamping of the umbilical cord
• Infant takes 1st breath
• Blood goes to the lungs
• Foramen ovale closes
• Ductus arteriosus closes
• Ductus venosus closes

FETAL DEVELOPMENT
• Organogenesis period
• Embryo – 1st eight weeks
 most critical time period while major organ systems are forming; may be affected by drugs or infections
• Fetus – after 8 weeks to birth
• Postterm or postmature infants – if born past 42 weeks
 have long nails, lots of hair on head, less vernix & fat, very dry skin
 major problems may occur due to the “old” placenta

Multifetal Pregnancy

Reproductive Anatomy and Physiology Male and Female Reproductive System

Chapter 2
Reproductive Anatomy and Physiology
Female Reproductive System
Female Reproductive System


• Pelvis
 Forms a fixed passage for the delivery of the baby
 Size & shape very important
 Ischial spines-palpated during vaginal exam; determine “station” or how far the baby’s head had descended down into the birth canal
• Pelvic Divisions – true pelvis most important
• Pelvic Measurements – fig 2.4
 diagonal conjugate-must be adequate size for passage of fetal head
• Pelvic types-fig 2-5
 Gynecoid or normal, female-type; round
 Android or male-type; heart shaped
 Anthropoid which has a long a-p outlet
 Platypelloid which has a wide transverse outlet

Female Reproductive System
Male Reproductive System
Male Reproductive System
Male Reproductive System
• Accessory Glands – produce secretions to:
 nourish the sperm
 protect the sperm from the acidic environment of the vagina
 enhance movement or motility of the sperm
• Seminal Vesicles
• Prostate gland surrounds the urethra just below the bladder
• Bulbourethral glands situated by the prostate gland

Male Reproductive System
PHYSIOLOGY OF THE SEX ACT
• MALE
 sperm can reach the woman’s vagina within 5 minutes & remain viable for 4-5 days
 millions of sperm are ejaculated, a few thousand reach the fallopian tube, but only one fertilizes each ovum
• FEMALE
 during orgasm the posterior pituitary gland secretes oxytocin which causes contraction of the uterus & dilation of the cervical canal which helps the sperm reach the fallopian tubes
 is also the reason why sexual abstinence is advised if there is a high risk for miscarriage or preterm labor
 egg lives only about 24 hours

Contemporary Maternity Care, Family, and Cultural Considerations lecture notes

Contemporary Maternity Care, Family, and Cultural Considerations

Maternity Care

• Definition and goals

 Maternity care: the care, support, instruction, and health promotion given by the nurse to the woman, partner, and family during pregnancy, labor & after birth.

 Goals: for the pregnancy, labor, & birth to be as normal as possible with the additional goal of having a healthy newborn

Current Trends

• Birth settings
 LDR
 LDRP
 Freestanding birth centers

• Technology & Maternity Care

 Much more advanced: intrauterine fetal surgery, NICUs

• Gender Selection
 Now able to select sex of fetus by sperm separation

Current Trends

• Providers of Maternity Care/Collaborative care
 Certified Nurse Midwives (CNM)
 Nurse practitioners
 Obstetricians/gynecologists
 Pediatricians
 Neonatologists –MDs who specialize in the care of newborns from birth to 28 days
 Geneticists
 Social workers
 Lactations specialists
Maternity Care
(…Cont’d)

• Health care delivery systems
 Managed care (HMOs, PPOs)
 Clinical pathways – maps of collaborative care given by the interdisciplinary health care team

• Government influences
 Healthy People 2010
 Statistics
 Standards of care (communication, documentation, patient privacy, and HIPAA)

Nursing Process
• Problem-solving approach using clinical judgment to provide individualized, comprehensive nursing care

• Steps:
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation

NIC, NOC, NANDA
• NIC: Nursing Intervention Classification

Nursing actions or interventions
• NOC: Nursing Outcome Criteria

Measurable outcomes reflecting patient responses to interventions
• NANDA: Nursing diagnoses
• RN is responsible for identification and coding of NIC and NOC
• LPN is responsible for working with and understanding these classifications
Culture
• Socially inherited characteristics handed down from generation to generation, shaped by values, beliefs, norms, and practices shared by members of the same background
• Cultural competence: the skills and knowledge needed to understand and appreciate cultural differences in order to adapt clinical skills and practices as necessary

Culture

• To provide culturally sensitive care, nurses should:
 Examine their own cultural beliefs
 Identify biases, attitudes, and prejudices
 Learn the practices of major cultures
 Recognize a woman’s right to make her own health care choices

Family Types
• U.S. Census Bureau definition: “a group of people related by blood, marriage, or adoption, living together”
 more modern definition is: “ 2 or more people who live in the same household, share a common emotional bond, & perform certain interrelated social tasks.”

• Family types
 Nuclear
 Blended or reconstituted
 Cohabitating
 Communal
 Extended
 Same-sex
 Single-parent
 Stepparent

Complementary and Alternative
Therapies (CAM)
• Alternative: therapies not traditionally recommended by health care providers; differ from conventional remedies
• Complementary: nontraditional methods used in conjunction with conventional therapy
• Integrated: using both CAM and traditional medicine to meet individual needs