1. Maternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton HisleyChapter 12--Processes &Stages of Labor and Birth

2. Critical FactorsIn Labor The Four Ps: passage, passenger,powers & psyche Passage: adequate pelvis? cephalopelvic disproportion (CPD) Suspect if presenting part does not engage inpelvis (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 todiminish size of skull Molding: head becomes narrower, longer, suturescan overlap--normal--resolves 1-2 days after birth Fontanelles: at junctures of skull bones 4. Passenger Fetus and fetal membranes Molding of head Fetal lie Longitudinal Transverse Oblique 5. Fetal Lieand 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) 6. Passenger (cont.) Fetal attitudeflexion Fetal presentation Cephalic Vertex Military Brow Face 7. Fetal Attitude 8. Advantages ofCephalic Presentations Head usually largest part of infant Molding Optimal shapesmooth and round 9. Assessment: FHT heard high on the abdomen,Leopolds, vaginal exam & US. Higher risk of anoxia from prolapsed cord, traumaticinjury to the after coming head,fracture of spine or arm,dysfunctional labor Usually delivered byC-sectionBreech presentation 10. Disadvantages ofBreech Presentation Risk of cord prolapse Presenting part less effective in cervicaldilation Risk of cord compression Risk of prolonged labor 11. Shoulder Presentation Occurs when fetus in transverse lie Cannot be delivered vaginally unlessrotation occurs 12. IMPORTANT TERMS Effacement: shortening and thinning ofcervix Expressed as a percentage (0% to 100%) Dilation: opening and enlargement ofcervix Expressed in centimeters (1 to 10 cm) 13. EffacementThinning of cervix(in %)StationDescent of fetal head(in cm) 14. Descent offetal head:StationFloatingEngagedAt outlet/crowning 15. Passageway +Passenger Relationship Engagement Station Ischial spines0 station Above ischial spines() minus station Below ischial spines(+) plus station +4 cm means that ... 16. Powers Uterine contractionsprimary force Maternal pushing effortssecondary force Characteristics of uterine contractions Increment Acme Decrement 17. PowersMaternal Pushing Efforts Bearing down sensation Urge to push No urge to push 18. Assessment ofUterine Contractions Characteristics Frequency Duration Intensity Palpation Electronic fetal monitoring 19. Onset of labor Usually begins between 38 & 42 weeks Mechanism is unknown Upper uterus contracts downward pushingpresenting part on cervix causing effacement anddilatation 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 20. False vs True Labor:ContractionsFalse Labor Benign and irregularcontractions Felt first abdominally andremain confined to theabdomen and groin Often disappear withambulation and sleep. Do not increase induration, frequency orintensityTrue Labor: Begin irregularly butbecome regular andpredictable Felt first in lower back andsweep around to theabdomen in a wave Continue no matter what thewomens level of activity Increase in duration,frequency, and intensity 21. False vs True Labor:CervixFalse Labor No significant changein dilation oreffacement No significant bloodyshow Fetus- presenting partis not engaged inpelvisTrue Labor Progressive change indilation andeffacement Bloody show Presenting partengages in pelvis 22. Critical Thinking A primigravida client has just arrived in thebirthing unit. What steps would be most importantfor the nurse to perform to gain an understandingof the physical status of the client and her fetus?A. Check for ruptured membranes, and apply a fetal scalpelectrodeB. Auscultate the fetal heart rate between and duringcontractionsC. Palpate contractions and resting uterine toneD. Perform a vaginal exam for cervical dilation, and performLeopold's maneuversE. Determine gestational age of fetus 23. First Stageof Labor: 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 morerapid dilation from 4 cm to full dilatation: stronger UCs Transition: 7-10 cm--intense, N/V, shaking 24. Landmarks Abbreviations are used First and last lettermaternal pelvis Middle letterfetus presenting part Examples ROA (right occiput anterior) ROP LSP 25. PsychosocialInfluences Other critical factors Readiness, educational preparedness, etc. Cultural views of childbirth Role transition facilitated by positivechildbirth experience Negative experience interferes withbonding and maternal role attainment 26. Childbirth Settings andLabor Support 27. AdmissionProcedures Establish positive relationship Collect admission data Initial admission assessments Focused Psychosocial assessment Cultural assessment Laboratory tests 28. Nursing Care Ongoing assessment Facilitate a positive birth experience Manage discomfort Advocate for patients needs Provide anticipatory guidance 29. Care of Laboring Patient Early LaborCouple excited, talkative, pain is manageable Initial physicalassessment & history Admission--rapport Fetal & UC monitoring Vaginal exams, q 2hours Vital signs Temperature q 4 hours-intactor q 2 hoursROM Educate regardinglabor Encourage comfort,position changes,bladder emptying Assess pain, paintolerance, preferredtype of labor/delivery Reassure regardingwhat is normal, reduceanxiety 30. Care of Laboring Patient Active LaborCouple quieter, discouraged, pain increasing 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 31. Labor Support Presence Promote comfort Environment Personal hygiene Elimination Supportive relaxation techniques 32. Critical ThinkingA client is admitted to the labor unit with contractions 2 to 3minutes apart and lasting 60 to 90 seconds. The client isapprehensive and vomiting. This nurse understands thisinformation to indicate that the client is most likely in whatphase of labor? A) Active B) Transition C) Latent D) Second 33. Fetal Assessment Position Fetal heart sounds Baseline FHR Presence of Variability Accelerations Decelerations 34. Interpretation ofFHR Tracings Consider contraction frequency andintensity, stage of labor, and earlier FHRpattern Reassuring Non-reassuring 35. 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 36. Second Stageof Labor Full dilation through birth of infant Urge to push Promote effective pushing Closed-glottis Open-glottis Position of comfort 37. Preparationfor Birth Bulging of the perineum and rectum Flattening and thinning of the perineum Increased bloody show Labia begin to separate 38. Dilatation & Effacement 39. Imminent Birth Crowning Burning sensation Intense pressure in rectum 40. Mechanisms of labor. A, Descent. B, Flexion.C, Internal rotation. D, Extension. E, External rotation.Cardinal Movementsof Birth 41. Head Rotation during Descent 42. CrowningIn the hospitalCrowningAlternative settings 43. Nursing Diagnosesfor Intrapartal Patient Pain Knowledge deficit Anxiety Fatigue Risk for infection Impaired fetal gas exchange 44. Third Stage Birth of baby to complete delivery ofplacenta Smaller, spherical uterus Elevation of uterus in abdomen Lengthening and protrusion of cord Gush of blood from vagina 45. Fourth Stage Delivery of placentathrough 1 to 2 hours after birth Monitor position and firmness of uterus Boggy, soft uterus Report immediately Initiate fundal massage Assess lochia Vital signs and urine output Shiveringoffer blankets 46. Fourth StageRisk Signs Hypotension Tachycardia Excessive bleeding Noncontracting uterus 47. Maternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton HisleyChapter 13Promoting Patient Comfort DuringLabor and Birth 48. PainDuring Labor and Birth Shaped by past experiences Assessing pain Physiological, psychological indicators Patient responses May be intensified by fear, anxiety, fatigue 49. Maternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton HisleyPhysical Causes of PainLabor and Birth 50. Pain Neurology Uterine ischemia Visceral paindull and aching Referred pain Somatic painsharp, burning, prickling 51. Pain Perceptionand Expression Highly personal and subjective Affected by gender, culture, ethnicity, andpast experiences Physiological/affective expression Increased catecholamines Increased blood pressure and heart rate Altered respiratory pattern 52. Factors AffectingMaternal Pain Response Physical Physiological Psychological Anxiety, fear, previous experience Support systems, childbirth preparation Environmental 53. NonpharmacologicalPain Relief Measures Maternal position and movement Breathing techniques Music Relaxation techniques Other attention-focusing strategies Guided imagery 54. Massage and Touch Effleurage Counterpressure Therapeutic touch Healing touch 55. Other Therapiesfor Comfort Hydrotherapy, hypnotherapy,aromatherapy Application of heat and cold Biofeedback, TENS, intradermal waterblock Acupressure/acupuncture 56. PharmacologicalPain Relief Measures Timing Nonpharmacological and pharmacologicalmeasures promote positive experience Informed consent 57. PharmacologicalMeasures Sedatives and antiemetics Systemic opiods & analgesics 58. Nerve Block Analgesia,Anesthesia Regional anesthesia- Epidural Local perineal infiltration anesthesia Pudendal nerve block Spinal anesthesia block Complications: maternal hypotension, decreasedplacental perfusion, ineffective breathing pattern 59. Systemic Analgesia Pre-medication Assessment: Pain level, VS, allergies, drug dependence(withdrawal), vaginal exam/progress in labor, UCpattern, fetal heart rate tracing Post-medication Assessment: VS, esp. RR, LOC, dizziness (bedpan), sedation,FHR Reversal agent: Naloxone (Narcan) Competes with narcotic for opiate receptors. Used inboth mom and baby. (avoid with narcoticdependence) 60. Regional AnesthesiaDefinition: Injection of local anesthesia to blockspecific nerve pathways Epidural/spinal anesthesia Systemic toxicity: cardiovascular collapse Side effects: Hypotension (preload with IV fluids),fetal distress on FHR tracing, spinal HA Contraindications: coagulation disorders, lowplatelet count (< 100), allergy, neurologic disease,aspirin or heparin use Nursing care: Preload IV fluids (LR), monitor BP,HR, anesthesia level, FHR, foley catheter,maternal positioning 61. Maternal Hypotension Prevention Preload IV fluids Requires constant nursing attendance Monitor vital signs 62. Epidural Anesthesia 63. Postdural Puncture(Spinal) Headache Leakage of cerebrospinal fluid Intensified in upright position Auditory and visual problems Autologous epidural blood patch Discharge instructions 64. Disadvantagesof Epidural Limited mobility Common side effects Accidental injection into blood vessel Sympathetic blockage Urinary retention, bladder distention 65. General Anesthesia Major risks used ONLY in emergencies Pre-operative preparation Anesthetic gases and medications Recovery room nursing care 66. Nursing CareRelated to Comfort Measures Assessment Ongoing and collaborative Diagnoses Anxiety Ineffective coping Acute pain 67. Nursing Care Expected outcomes Plan of care Individualized Modified as needed Collaborative approach 68. Maternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton HisleyChapter 14Caring for the WomanExperiencing ComplicationsDuring Labor and Birth 69. Dystocia Long, difficult, or abnormal labor May arise from Powers Passenger Passageway 70. Dysfunctional Labor Pattern:Hypertonic Strong, painful, ineffective contractions Contributing factormaternal anxiety Occiput-posterior malposition of fetus Management Rest, hydration, sedation Facilitate rotation of the fetal head 71. Dysfunctional Labor Pattern:Hypotonic Contractions decrease in frequency andintensity Maternal and fetal factors that produceexcessive uterine stretching Management Walking, position changes Augmentation of labor 72. Precipitate Laborand Birth Rapid labor & birth 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 andplacenta 73. Pelvic Structure Alterations Pelvic dystocia Soft tissue dystocia Trial of labor To assess safety of vaginal birth 74. Obstetric InterventionsAmniotomy Artificial rupture of membranes Augment or induce labor Nursing Careful monitoring of vital signs, cervicaleffacement/dilation, station, FHR, contractions Document regarding amniotic fluid 75. Obstetric InterventionsAmnioinfusion Risks: infection, overdistention of uterus,increased uterine tone Nursing Careful monitoring of infusion, intensity and frequencyof contractions, and maternal vital signs Educate Pharmacological induction of labor Nonpharmacological stimulants of labor 76. Episiotomy Midline or mediolateral Nursing care: Assess forapproximation,swelling, oozing,infection Relief for pain: icepack in first 24hours, then heat,local analgesicspray, witch hazelpads (Tucks), sitzbath, peri-bottle forvoiding, painmedications 77. Induction of Labor Indications for induction Bishop score Cervical ripening agents Mechanical methods Oxytocin Augmentation of labor 78. InductionNursingConsiderations Informed consent Careful monitoring of labor Discuss pain relief measures Position changes Keep patient and support person informedof progress 79. Instrumentation Assistance Forcepsof Birth Indications: unable to push, arrested descent,need a quick delivery, breech Associated with: maternal/fetal birth trauma, rectalsphincter tear, urinary stress incontinence Vacuum extraction Advantages: fewer lacerations, less anesthesianeeded, Disadvantages: marked caput,cephalhematomas, scalp laceration/bruising 80. Maternal ComplicationsHypertensiveDisorders Preeclampsia-eclampsia, HELLP syndrome Nursing Careful assessments Monitor lab values Administer platelets as appropriate Ongoing education 81. Maternal ComplicationsDiabetes Fetal lung maturity Intrapartum management-Maternal hydration,-Insulin, and-Blood glucose levels Labor: normal progression of labor Upright or side-lying position Encourage breastfeeding 82. Preterm Laborand Birth Careful maternal monitoring FHR monitoring *** Identify and report symptoms suggestive offetal hypoxia Assess psychological status 83. Labor and BirthComplicationsFetal Fetal malpresentation Version: external or internal Shoulder dystocia Cephalopelvic disproportion Multiple gestation Non-reassuring FHR patterns 84. Macrosomia/Shoulder Dystocia Wt. > 4500 gms (9-10 lbs) Associated with: DM, Gestational DM, Multiparity, Postdates, obesity Risks: Shoulder dystocia, difficulty delivering the shoulders afterhead is delivered (obstetrical emergency) Maternal: vaginal/cervical tears, pp hemorrhage, rupture Fetal: compressed cord, fractured clavical, asphyxia &neurologic damage, brachial plexus injury (ErbsPalsy) S/S: Turtle sign Nursing interventions: McRoberts maneuvers,suprapubic pressure. PP: assess for uterineatony/hemorrhage; trauma, cerebral or neurologicdamage to baby 85. Video: youtube.com/watch?v=jV6g427UMxY&feature=related 86. McRoberts Maneuvers Video 87. Amniotic FluidComplications Oligohydramnios Hydramnios Meconium Nuchal cord 88. Other Complications Uterine rupture Obstetric emergency Uterine inversion Umbilical cord prolapse 89. Maternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesSusan WardShelton HisleyCollaboration in PerinatalEmergencies 90. Perinatal Fetal Loss What to say What NOT to say Nursing considerations< 20 weeks> 20 weeksname & hold the babyfuneral/memorial serviceResolve support group 91. Cesarean Birth Indications Health of mother or fetus is jeopardized Ethical considerations Surgical procedures Surgical and postoperative care Vaginal birth after cesarean 92. Cesarean BirthIndications for:Maternal Factors Active genital herpes AIDS/HIV + Cephalopelvic disproportion Severe preeclampsia,diabetes Obstructive tumor Ruptured uterus Previous c-section Failed induction/fx to progressin labor Elective?Placenta Factors Placenta previa Placental abruption Umbilical cord prolapseFetal Factors Breech, transverse lie Macrosomia Extreme low birth wt Fetal distress Fetal anomalies Multiple gestation 93. Cesarean Birth(cont) Mortality/morbidity 4 x higher thanvaginal birth in US.Most risk assoc. withemergency c-section Incision Skin vs. uterine Classical vs lowtransverseMaternal Complications Infection Anesthesia reactions DeepVeinThrombophebis Bleeding Ureteral/bladder injury Increase risk forsubsequent pregnancy PlacentaAcreta/Previa,Infertility 94. Postterm Pregnancy > 42 weeks Maternal risks: trauma/hemorrhage due tolarger baby, operative delivery/c-section Fetal risks: placental changes thatoxygenation to baby and mortality rate,oligohydramnios (cord compression duringlabor), LGA baby (birth trauma, shoulderdystocia), meconium aspiration Management: > 40 wks, NST, BPP ormodified BPP (NST & AFI), induction 95. Post-Op Care Assess fundus/bleeding, vital signs, DVT. Antibiotics, if infection Pain: Duramorph. Breakthrough pain meds.Benadryl for itching. Zofran for nausea. Clear liquids and advance as tolerated. Assess for GI function. Bowel sounds? Passingflatus? Ambulation. Pre-medicate, teach splinting withpillow. 96. Critical Thinking A laboring multipara ishaving intense uterine contractionswith incomplete uterine relaxation betweencontractions. Vaginal examinations reveal rapidcervical dilation and fetal descent.What should the nurse do first?A) Notify the physician of these findings.B) Place the woman in knee-chest position.C) Turn off the lights to make it easier for thewoman to relax.D) Assemble supplies to prepare for birth. 97. Case Study: Linda MandellaLinda Mandella is in labor with her third baby at the birth center.She wishes to experience a natural, unmedicated birth. Linda is groaningand crying. A cervical examination performed 2 hours ago revealed thatshe was 6 cm dilated, and 100% effaced.Lindas family is present, and this is the first time that they have been ableto attend and support her during the labor and birthing process. The familymembers are shouting and blaming the nurse for causing Linda to suffer.They demand that the nurse give Linda painkillers to ease her suffering andpain.Critical Thinking Questions 1. What are the priority nursing diagnoses at this time? 2. What are the expected outcomes associated with these diagnoses? 3. Describe the teaching/learning needs related to the scenario thatcorrespond to the priority nursing diagnoses. 4. List nursing interventions with rationales that correspond to the prioritynursing diagnoses.