Chapter 22--Processes & Stages of Labor and Birth

1. Chapter 22--Processes & Stages of Labor and Birth

2. Critical Factors In Labor • The Four P’s: passage, passenger, powers & psyche • Passage: • adequate pelvis? • cephalopelvic disproportion (CPD) • Suspect if presenting part does not engage in pelvis (0 station)

3. Passenger • The fetus: head is largest diameter • Fetal head: 4 bones with 3 membranous interspaces (sutures) that allow bones to move & overlap to diminish size of skull • Molding: head becomes narrower, longer, sutures can overlap--normal--resolves 1-2 days after birth • Fontanelles: at junctures of skull bones

5. Fetal Attitude

6. Fetal Lie and Presentation • Leopold's maneuvers/US • Longitudinal lie: Vertical • Presenting part: • cephalic (head), • vertex (occiput), chin (mentum) • breech (buttocks or feet) (c-section) • sacrum • Transverse lie: Horizontal (c-section) • Presenting part: shoulder (acromion)

7. Fetal position: • mom’s pelvis is divided into 4 quadrants: RA, RP, LA, LP • determine which quadrant presenting part (occiput) is pointing towards

8. Passenger • Occiput Anterior (LOA & ROA): most common positions & easiest for birth • Occiput Posterior (LOP & ROP): • can prolong both 1st & 2nd stage of labor • back pain during UCs (back labor) • Instruct partner in sacral pressure during UC’s • Try “all fours,” knee-chest, or alternate side-lying positions to encourage baby to rotate to anterior position

9. Powers • Contractions: supplied by fundus of uterus • Involuntary, become stronger as labor progresses • Abdominal muscles: “pushing” by mom (2nd stage) Psyche • Psychological state & feelings of mom • Coping skills • Anxiety, fear, stress • Labor support

10. Onset of labor • Usually begins between 38 & 42 weeks • Mechanism is unknown • Upper uterus contracts downward pushing presenting part on cervix causing effacement and dilatation • Premonitory signs of labor: • Lightening, Braxton-Hicks contractions (false labor), • cervical changes (ripening), • bloody show (mucous plug), • rupture of membranes (ROM), • sudden burst of energy

11. False Labor Benign and irregular contractions Felt first abdominally and remain confined to the abdomen and groin Often disappear with ambulation and sleep. Do not increase in duration, frequency or intensity True Labor: Begin irregularly but become regular and predictable Felt first in lower back and sweep around to the abdomen in a wave Continue no matter what the women’s level of activity Increase in duration, frequency, and intensity False vs True Labor:Contractions

12. False Labor No significant change in dilation or effacement No significant bloody show Fetus- presenting part is not engaged in pelvis True Labor Progressive change in dilation and effacement Bloody show Presenting part engages in pelvis False vs True Labor:Cervix

13. Critical Thinking • A primigravida client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus? A. Check for ruptured membranes, and apply a fetal scalp electrode B. Auscultate the fetal heart rate between and during contractions C. Palpate contractions and resting uterine tone D. Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers E. Determine gestational age of fetus

14. Stages of Labor: First Stage • 0 to 10 cm: dilatation--opening of cervix) • Latent: slowest part of the process--slow dilation, mild contractions • from onset of regular UCs to rapid dilatation (about 3-4 cms) • Active: labor “picks up steam”--period of more rapid dilation • from 4 cm to full dilatation: stronger UCs • Transition: 7-10 cm--intense, N/V, shaking

15. Station Descent of fetal head (in cm) Effacement Thinning of cervix (in %)

16. Descent of fetal head: Station Floating Engaged At outlet/crowning

18. Dilatation & Effacement

19. Initial physical assessment & history Admission--rapport Fetal & UC monitoring Vaginal exams, q 2 hours Vital signs Temperature q 4 hours-intact or q 2 hours ROM Educate regarding labor Encourage comfort, position changes, bladder emptying Assess pain, pain tolerance, preferred type of labor/delivery Reassure regarding what is normal, reduceanxiety Care of Laboring PatientEarly Labor • Couple excited, talkative, pain is manageable

20. Care of Laboring PatientActive Labor • Transition (7-10 cm): Yikes! “out of control”, shaking, nausea/vomiting, sweating, pain is intense • Prepare for delivery • Second stage (Pushing): • Educate/instruct regarding pushing • Assess urge to push and fetal descent • Encourage/motivate patient, assess fatigue • Monitor fetal/maternal response to pushing bulge, crowning • Signs of imminent birth: perineal bulging • Couple quieter, discouraged, pain increasing

21. Stages of Labor:Second Stage • Pushing & descent of baby (STATION) • Full dilatation (10 cm) to birth • Important NOT to push until full dilation • Assessment: Urge to push? Rectal pressure? • Push only with UC’s • Crowning: baby’s head is visible at the opening of vagina • Cardinal movements of labor youtube.com/watch?v=Xath6kOf0NE&feature=related youtube.com/watch?v=duPxBXN4qMg&feature=related

22. Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.

23. Head Rotation during Descent

24. Crowning Crowning In the hospital Alternative settings

25. Stages of Labor: Third Stage • Placental stage: from birth to delivery of placenta • Placental separation from uterine wall (rise of fundus, sudden gush of blood, lengthening of umbilical cord) • Entire lining of uterus shed • Expulsion of placenta • Normal blood loss: 300-500 mL • If placenta does not deliver spontaneously, can be delivered manually • Pitocin infusion started immediately post delivery of placenta

26. Critical Thinking • A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds. The client is apprehensive and vomiting. This nurse understands this information to indicate that the client is most likely in what phase of labor? • A) Active • B) Transition • C) Latent • D) Second

27. Methods of Induction • Prostaglandins (Cervidil, prostin gel, Prepidil, Cytotec) applied intravaginally for cervical ripening • Pitocin (oxytocin) by IV • Amniotomy or stripping of membranes • Sexual intercourse • Nipple stimulation • Herbal preparations

28. Indications for induction of labor • Post-term pregnancy (≥ 42 weeks) • Premature or prolonged rupture of membranes • Maternal complications (Rh isoimmunization, Diabetes, Pulmonary disease, Pregnancy-induced hypertension) • Chorioamnionitis • Suspected fetal problems- Intrauterine Growth restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells) • Fetal demise

29. Contraindications to Induction • previous c-section • placenta previa or abruption • prolapsed cord • fetal bradycardia, nonreassuring fetal status • vaginal bleeding of unknown cause • cephalopelvic disproportion • active genital herpes

30. Cervical Ripening Assessment • Bishop Score- rating that determines if the cervix is ready for induction • Fetus must be in vertex position • Baseline data on fetal and maternal well-being (at least half an hour of monitoring) • Fetal monitoring and uterine contraction monitoring is imperative • Notify MD if hyperstimulation or fetal heart rate distress is noted

31. Oxytocin Induction • Confirmation that the baby is in a cephalic (vertex) position (head down) • V/S done at least every 30 minutes and when dose is titrated • FHTs and UCs assessed every 30 minutes • Titration of oxytocin till UCs every 2-3 minutes • Cervical dilation should be 2 cm/hr (ideally) • Reassuring FHTs between 110-160 beats/min

32. When to Discontinue Oxytocin Hyperstimulation-frequency of UCs less than 2 minutes apart -Now being called tachysystole -Inadequate uterine relaxation between contractions <60 sec between UC’s Fetal Distress-any decelerations or decreased baseline variability

33. Childbirth at Risk Complications of Labor or Delivery

34. Critical Thinking The client in active labor is requesting pain relief. The physician orders epidural anesthesia for the client. Which of the following parameters should the nurse be prepared to assess immediately after administration of the epidural? • A) For headache. • B) For urinary retention. • C) The blood pressure. • D) The maternal pulse rate.

35. Precipitous Labor &Birth • Labor in < 3 hours • Risk factors: • Multiparity, oxytocin or amniotomy, hx of precipitate labor • Risks for injury • Maternal: cervical, vaginal & perineal lacerations with possible hemorrhage, pain, anxiety • Fetal: Birth trauma (intracranial bleed, brachial palsy), meconium-stained fluid, fetal distress • Management: close monitoring for cervical changes, induction

36. Postterm Pregnancy • > 42 weeks • Maternal risks: trauma/hemorrhage due to larger baby, ↑operative delivery/c-section • Fetal risks: placental changes that ↓oxygenation to baby and ↑mortality rate, oligohydramnios (↑cord compression during labor), LGA baby (↑birth trauma, shoulder dystocia), meconium aspiration • Management: > 40 wks, NST, BPP or modified BPP (NST & AFI), induction

37. Malpresentations • Occiput-posterior (OP) • Prolonged labor, back labor (sacral nerve compression), arrested dilatation/ descent, perineal tears • Usually vaginal, but may need C-Section if baby doesn’t rotate • Management: positioning (side-lying, knee-chest or hand-knees), sacral pressure during UC’s • Transverse Lie • Associated with: pendulous abdomen, uterine masses/fibroids, congenital abnormalities of uterus, hydramnios • Attempt External Cephalic Version, if unsuccessful obligatory C-section

38. Malpresentations (cont) • Breech presentation Assessment: FHT heard high on the abdomen, Leopold’s, vaginal exam & US. • Higher risk of anoxia from prolapsed cord, traumatic injury to the after coming head, fracture of spine or arm, dysfunctional labor • Usually delivered by C-section

39. External Version • External cephalic version (37-38 wks): abdominal manipulation to change fetal presentation • Contraindications: multiple gestation, fetal breech is engaged in pelvis, oligohydramnios, nonreactive NST, nuchal cord, vaginal bleeding, IUGR, ROM. • Risks: immediate cesarean birth • Nursing actions: NPO 8 hrs, NST, IV line, terbutaline, continuous FHR, US used to guide manipulations, assess for: labor, fetal distress. O- moms need Rhogam following the procedure

40. Macrosomia/Shoulder Dystocia • Wt. > 4500 gms (9-10 lbs) • Associated with: • DM, Gestational DM, Multiparity, Postdates, obesity • Risks: • Shoulder dystocia, difficulty delivering the shoulders after head is delivered (obstetrical emergency) • Maternal: vaginal/cervical tears, pp hemorrhage, rupture • Fetal: compressed cord, fractured clavical, asphyxia & neurologic damage, brachial plexus injury (Erb’sPalsy) • S/S: Turtle sign • Nursing interventions: McRoberts maneuvers, suprapubic pressure. PP: assess for uterine atony/hemorrhage; trauma, cerebral or neurologic damage to baby

41. Video: youtube.com/watch?v=jV6g427UMxY&feature=related

42. McRoberts Maneuvers Video

43. Multiple Gestation • Monozygotic (identical) twins: can have 1 or 2 placentas, chorions, or amnions (↑risk if all shared) • Dizygotic (fraternal) twins: 2 of everything. • Dx: faster than usual growth of uterus, ↑AFP, HCG, Ultrasound • Risks: • Maternal: SAB, gestational DM, HTN/preeclampsia/HELLP, hydramnios, PT labor & delivery • Fetal: Preterm birth, twin-to-twin transfusion

44. Multiple Gestation (cont) • Management: • US to determine what type of twins • Prevention of PT labor/routine cervical measurements (US) • NST surveillance • Birth: depends on maternal & fetal complications and fetal position/ presentation • Examination of placenta • Close monitoring PP for hemorrhage (atony)

45. Abruptio Placentae • Premature separation of placenta from uterine wall • S/S: sharp, stabbing pain high in fundus, heavy bleeding (may be occult), hard, board-like uterus, tense, painful uterus, signs of shock due to blood loss, Port-Wineaminotic fluid if ROM. • Predisposing fx: ↑parity, adv. maternal age, short umbilical cord, chronic HTN, PIH, direct trauma, vasoconstriction from cocaine or cigarette use • Fetal distress on monitor. Can progress to DIC.

47. Abruptio Placentae (cont) • Management: • Emergency. Immediate c-section if birth not imminent. • Lg. gauge IV • O2 via mask, fetal monitoring, maternal VS, lateral positioning, labs, blood transfusion (have 2 units avail) • CBC (H&H), Fibrinogen levels, platelet count, PT/PTT, fibrin degradation products ( sx of DIC)

48. Placenta Previa • Low implantation of placenta (1 in 200) • abrupt, painless, bright red bleeding • Associated with ↑parity, adv. maternal age, previous c-section or uterine curettage, multiple gestation • Dx: ultrasound. May resolve as pregnancy progresses. • Bleeding common around 30 wks: Bedrest, VS, IV fluids, type & cross-match, observe for bleeding • Emergency: assess bleeding, hx, uc’s/labor, • NEVER do vaginal exam !!! C-Section delivery, possibly before 37 wks. Steroids for mom. Watch for pp hemorrhage. • Differential dx: abruptio/previa

49. Placenta Previas Low-lying Marginal Complete Partial

50. Prolapsed Cord • Loop of umbilical cord slips down in front of the presenting part • S/S: deceleration of FHT: bradycardia, persistent variable decels, cord palpatedor seen in vagina • Associated with: • Premature rupture of membranes • Transverse or breech presentation • Multiple gestation • Placenta previa • Hydramnios • CPD (non-engagement of fetal head)