Ob Study Gizzude #3

8/11/2019 Ob Study Gizzude #3

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OB Exam #3

Intrapartal Period: From the beginning of contractions through delivery of the newborn and placenta and the first 1-4 hours.

Intrapartal Care: Medical and nursing care given to pregnantwoman and family during labor and birth.

Length of Laboro Primigravida

Average: 12-18 hours I in 100 women < 3 hours 1 in 9 women > 24 hours

o Multipara Average: 8-10 hours

7 in 100 women < 3 hours 1 in 33 women > 24 hours

Factors Affecting Labor:

o 1.) Passageway The pelvis & birth canal Factors affecting the passage:

Musculoskeletal deformities Uterine neoplasms ( fibroids) Bicornuate uterus (2 horns) Maternal dwarfism Nutritional deficiencies/diseases Pelvic trauma


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o 2.) Passenger Passenger: Fetal head size and position Refers to the ability of the fetus to move through the

passage. This is based upon:

Biparietal diameter o Is usually the most important measurement o This is the distance between the parietal

bosses o The head can mold-change shape to fit

through the pelvis


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o The size of the fetal head and capability ofthe head to mold to the passageway

o The head is the largest partof term infant

Passenger: Fetopelvic relationships o Fetal lie

Relationship of the long axis of the fetusto long axis of the mother

Longitudinal (up and down withmother)

Oblique (diagonally) Transverse (fetus horizontal)

o Fetal Presentations Part of fetus that enters maternal pelvis 3 types:

o 1. Cephalico

2. Breech 3% Presentations:

o Frank Breech

Station

Transverse lie

Increased fetalmortality/morbidity

Associated with:o Prematurityo Placenta preo Multiparityo Some

congenitalanomalies


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Fetal Attitude o Relationship of fetal parts to one another (degree or

extension of fetal head in cephalic presentations) o Flexion is what we want (vertex)

Fetal Positionso Relationship of a particular reference point of the

presenting part of the fetus to the maternal pelvis


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Occiput anterior (OA)= results in easiest vaginal birth

Occiput posterior (OP)= may slow descent


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Control Medicalization of childbirth Pain and perception of pain

o 5.) Position Squatting position opens diameter about 20%

True Labor vs. False Labor

True Labor Contractions :

o Regular intervals

o Start in back and sweep to abdomen o Increase in intensity/duration o Intensified by walking

Bloody show: o Usually present

Effect of sedation: o Does not stop contractions

Cervical effacement and dilation

False Laboro Contractions:

o Irregular intervals o Mostly in abdomen


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o Intensity is same or variable and dont become morefrequent

o Walking has no intensifying effect o NO bloody show o Effect of Sedation

o Tends to decrease # of contractions o No cervical change

Labor Onset

o Theories of labor initiationo Maternal factor theories

1. Uterine size

once gets to certain size initiates prostaglandins 2. Pressure on cervix 3. Progesterone withdrawal

in animals decreased progesterone leads to labor 4. Oxytocin stimulation

o Fetal factor theories 1. Placental aging

ages after 41 weeks after pregnancy 2. Fetal endocrine control 3. Prostaglandin synthesis


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Signs/Symptoms of Impeding Labor

o Lightening/engagemento Lightening-Descent of fetus into the pelvis o Engagement- Widest diameter of presenting

part Has passed the inlet (0 station)

o Baby drops; lightening occurs

o Presenting part: Engaged Signs and symptoms of

the baby engaging: Urinary frequency, backache, leg pain,

dependent edema, and easier respirations o Presenting part: Dippingo Presenting part: Floating

o Braxton Hicks contractionso Irregular, intermittent contractions o May be felt in groin, fundus

o Loss of mucus plug

Presenting part:Floating

Presenting part: Dipping

Presenting part: Engaged


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o Thick mucus which has sealed the endocervical canal duringpregnancy

o Prevents ascent of bacteria or other substances o Expelled when cervical dilatation begins o May indicate labor within a few days

o Cervical changeso Cervix is opening o Softening, ripening o Cervical dilatation/effacement o Position change

o

o

Cervical Changes


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o Rupture of membraneso Diagnosis

Pooling Nitrazine paper Nitrazine paper turns blue Amniotic fluid (Alkaline) Urine (Acidic)

SSE - ferning o Teaching

Nothing in vagina Notify HCP Hand washing Temp q2 hours

Change pads often o Nursing actions when SROM occurs o Check FHR

The very first thing to check should be the fetal heartrate; bc of pressure cord may all of a sudden pushdown (prolapsed cord) always rule out

o Other symptoms of laboro Burst of energy or fatigue/tension o

Weight loss 1- 3 lbs a couple days before labor; dont know whatcauses this

o Diarrhea, not feeling well

History of Childbirth in America

o Evidence based Practice? o Evidence-based obstetric care is a relatively new concept,

which had its origins in the early 1970s when Iain Chalmersand his colleagues in Oxford responded to the statement ofArchie Cochrane that much of the evidence underpinningobstetric (and other) practices was flawed. (J. King, 2005)


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First Stage of Labor

o Definition : onset of contractions to complete dilatation (0-10cm) o Physiologic changes

o Cardiovascular Increased cardiac output, little HR/BP change

o GI Slowing of gastric emptying

Motility Absorption N/V

o Renal Full bladder

Increased pain, slows labor & fetal descent Proteinuria

o Respiratory Exhales more CO2

o Latent Phaseo Definition : onset of regular contractions- 3-4 cm o Length :

Primigravidas: 8-20 hours Multiparas: 5-14 hours

o Contractions


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Irregular Q 10-20 mins 15-45 second duration Increase in frequency, duration, intensity to q 3-5

minutes 60 sec long o Emotional Responses

Anxiety, relief, excitement o Active Phase

o Definition: 3-4 cm- 7-8cm o Contractions

Q 3-5 min, 45-60 seconds, moderate intensity o Emotional response

Serious, turns inward Decreased energy

Fatigue o Transition Phase

o Definition: 7-8 cm--- 10cm o Contractions

Q 2-3 min, 60-90 seconds duration, strong intensity o Signs/Symptoms

Nausea, vomiting, trembling limbs, increased bloodyshow, urge to push, pelvic pressure, irritability

o Emotional Response Discouragement, irritability, panicky, impatient, feels

out of control Nursing Care for Normal Labor

o Assessmento maternal and fetal status, labor status

o Diagnosis o Active labor, reassuring FHR, tolerating labor, need for

hydration, nutrition, ambulation, monitoring, consultation o Plan

o Ambulation, hydration, FHR, privacy, pain medication o Implementation o Evaluation


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Assessment

1. Maternal VS q 30-60 min, T q 4 hours; if ROM, q 2 hours

2. Urine dipstick

3. Assess fetal lie and fundal height

4. Determine fetal position, # of fetuses, approximates fetal size

Leopolds maneuvers

5. Assessment: Uterine Contractions o Onset; Frequency, Duration, Intensity

a.) Palpation Figure out Indentability of uterus

o Mild- feels like end of nose


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easily identifiable o Moderate-

feels like chin; some indentation o Strong/firm-

feels like forehead,, cannot beindented

b.) Tonus (electronic fetal monitoring)- Tells whenbut not how strong they are

External (toco transducer)- Measurespressure inside the uterus

Internal (intrauterine pressure catheter) o (ICPC) o 30-50 mm Hg needed o Risks: infection, uterine rupture

6. Assessment: Vaginal Exam o Cervical effacement and dilatation o Station o Presenting part o Position- suture and feel for soft spot o Status of membranes- did it rupture? Feels like balloon o

(cervical exam may need to be done every 2 hours; somewomen may hate this bc the cervix may be tippedbackwards)

7. Assessment: Vaginal Discharge o Bloody show

Amount Characteristics

Mucus-y rather than really bloody o Evaluate amniotic fluid

Type of rupture (SROM, AROM) Color (clear) If brown or stool in it than risk factor Amount Odor

8. Assessment: Fetal status o Auscultation of fetal heart rate (FHR)


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Doppler or Doptone Normal range 120-160 Check q 15-30 minutes in active labor Decelerations Changes in variability Rate

o Intermittent fetal heart rate auscultation allows: Freedom of movement Upright positions Patient satisfaction Natural progression of labor

Location of FHR


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o External Fetal Monitoring

o Internal Fetal Monitoring o Insertion of Fetal scalp electrode (FSE)


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Factors indicating use of electronic fetal monitoringo Abnormal contraction stress test/decreased fetal movement o Multiple gestation o Placenta previa or abruption o Oxytocin infusion o Fetal bradycardia/tachycardia o Maternal complications o Postdates or pretermo Meconium stained fluid


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FHR Changes

o Baseline FHR o Normal: 110-160 o Need >10 minutes to establish a baseline (which is between

contractions o Bradycardia

o Definition


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o Tachycardia o Definition: >160 bpm o Fetal distress if it lasts or accompanied by late decelerations o No variability. Mother gets sick then fetus follows.o Causes:

Maternal fever/infection

Meds Prolonged fetal activity

FHR CHANGES: FHR ACCELERATIONS

FHR CHANGES: FHR DECELERATIONS


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EARLY DECELERATIONS

Head getting compressed pretty common


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LATE DECELERATIONS

Does not start to go down until middle and does not recoveryby the end. Should recover by the end of the contraction.Thought to be due to uteral placenta deficiencies. Flatter theline the more concerning.

VARIABLE DECELERATIONS

Think of Ws or Vs . Goes down quick and comes back quick.Usually from cord compression. Will try to turn the mother andintervene.

V-E-A-L-C-H-O-P


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FHR descriptors -- Due to: Variable decelerations Cord compression Early decelerations Head compression Accelerations Ok Late decelerations Placenta insufficiency

Prolonged Deceleration

o Visually apparent FHR decrease below baseline o 15 bpm or more o Lasting 2 min or more o Less than 10 min from onset to return to baseline o Not good

FHR CHANGES: Baseline Variability

o Baseline variability o Fluctuations in the FHR of 2 cycles/min or greater o Looking for lots of fluctuations

Absent- amplitude range undetectable Minimal- amplitude range detectable but < 5bpm Moderate- (normal)-amplitude range of 6-25 bpm Marked- amplitude range >25 bpm


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FHR VARIABILITY

Moderate FHR Variability FHR Variability: Absent


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o Cochrane analysis (12 RCTs, n >37,000)-comparing EFM tointermittent auscultation (IA) found that EFM:

o Increased C/S o Increased use of vacuum and forceps o No difference in perinatal mortality o No difference in cerebral palsy o No difference in Apgars


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Unable to maintain adequate oral intake In preterm labor to diminish contractions

o Saline lock- Intermittent IV access Group B Strep prophylaxis

10. Assessment: Comfort Measureso Increase use of non-pharmacologic methods of pain relief

o Ambulation and freedom of movement o Hydrotherapy during the active phase of labor o Continuous labor support

11. Position Changeso Ambulation and freedom

of movement in labor issafe, enhances patientsatisfaction, andfacilitates the progress oflabor

o Lying supinedecreases blood

flow Blood flow tothe fetus isreducedwhen womenlie on theirbacks due tocompressionof the venacava by thegravid uterus


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o Continuous labor support should be the standard of care for alllaboring women

o Historically, partners and support persons banned from hospitaldelivery suites to maintain asepsis

o Alternative childbirth movement of 1970s brought fathers intodelivery rooms

o Klaus and Kennell study (1986) renewed interest in supportpersons for laboring women

o Evidence Based Practice: o Continuous Labor Support

Cochrane review (16 RCTs, n >13,000)- continuouslabor support:

Increased: o Spontaneous vaginal birth o Shorter labor o Satisfaction

Less use of pain meds

12. Keep support people informed of progresso Support persons include midwives, doulas, one-one nursing care,

partners, families, and friends o Supportive care in labor:

o Emotional support o Comfort measures o Information o Advocacy

Pain Management

o Causes of intrapartal pain: o Uterine contractions o Uterine stretching o Dilating and effacing of the cervical os


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o Fetal presentation

Pain in Labor

o Physiologic responses: o Increased BP, P, R, perspiration o Increased pupil diameter, muscle tension

o Nonverbal


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o Withdrawal o Hostility o Depression

o Verbal o Pain o Moaning o Groaning

Interventions for Pain in Labor

o Depends on: o Gestation o Frequency, duration, intensity of contractions o Labor progress o Maternal response to pain and labor

Allergies/sensitivities

Factors Affecting Pain Perception

o Previous experience, personal expectations o Cultural concept of pain o Rapidly progressive labor o

Fear, anxiety, and fatigue

Nursing Goals for Pain Management

o Provide maximal pain relief with maximal safety for mother andinfant

o Collaborate with woman and birth attendant to determine mosteffective pain relief method

Non-Pharmacologic Pain Management

o Relaxation Techniques o Controlled breathing (Lamaze, Bradley)

o Why Helpful? o Hyperventilating

o Mouth and hand get tingly


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o To cure hyperventilation: brownbag no smells. Help changebreathing to keep going

o Visual imagery/hypnosis; use of focal point o Movement, position changes, ambulation o Hydrotherapy

o Background: Hydrotherapy has not been routinely used inlabor due to the concern that it would increase the risk formaternal and or fetal infection

o Evidence Based Practice: Hydrotherapy is safe and effective indecreasing pain during active labor

Cochrane analysis (8 RCTs, n=2939): Hydrotherapy during active labor decreases:

o Use of anesthesia o Reported Pain

No adverse maternal or neonatal outcomes Touch

o Acupressure/acupuncture o Skin stimulation (Gate Control Theory of

Pain) o Massage/counter pressure o

Application of hot or cold o Other non pharmacologic methods

o Music o Aromatherapy-lavendero TENS (transcutaneous electrical nerve stimulation) o Sterile water papules

Pharmacologic Methods of Pain Management

Drugs o Narcotic analgesics

o Morphine, Demerol, Nubain, Numorphan, Stadol, Fentanylo Morphine- not given because its long acting

Maternal effects


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N/V, mild respiratory depression, transientmental impairment

Fetal effects Neonatal Respiratory Depression* Reverse with opiate antagonist

(Naloxone/Narcan) Nursing actions

Monitor VS, FHR Safety precautions Avoid administration within 1-4 hours of

delivery and with no signs of fetal distress

o Barbiturates o Infrequent useo Will keep in hospital, long acting drugo Early or prodromal laboro Relieve anxiety/promote sleep

Secobarbital (Seconal) Pentobarbital (Nembutal)

Diazepam (Valium) *not recommendedo Tranquilizers

o Infrequent useo Reduce anxietyo Potentiate narcotics

Hydroxyzine (Vistaril/Atarax) Only given PO or IM bc it really burns. Never give SQ!!

o Intrathecal o Narcotic injected into subarachnoid spaceo Side effects:

Pruritus, N/V, Urinary Retention


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Epidural

Anesthesia

o Maternal effects o Hypotension

- FETAL DISTRESS fetal side effect of epidural in labor is fetal distress due

to maternal hypotension. Usually around 5cm mark.Give bolus of IV fluids before epidural to stophypotension.

o Allergic/toxic reaction o Accidental spinal puncture-headache! o Respiratory paralysis o Partial or total anesthetic failure


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o Difficulty pushing o Difficulty voiding

Cath may be put in to help voiding. Dont let be onback for too long.

o Effects on labor/delivery process ? Increase length of labor, increase operative delivery

o Push caffeinen to get rid of HA postpartum o Goes to lungs because of positioning o Switch women onto different sides every hour

o Fetal effects


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Will most likely see with-hold breath and push as longas possible 3x per contraction

o Spontaneous (open glottis) pushing Non epidural will push when feels urge

o Background:o Second stage without epidural:

Spontaneous urge to push after a short latent period

Spontaneous bearing down reflex with vertex descendsto or near pelvic floor

o Second stage with epidural Suppressed bearing down reflex- higher levels of

vacuum and forcep use Higher rate of instrumental birth Longer second stage

Evidence Based Practice:o Spontaneous vs Closed Glottis Pushingo Sustained Valsalva bearing down efforts:

o Increases: FHR decelerations Maternal fatigue Perineal tears Urinary stress incontinence postpartum

o Decreases: Umbilical cord pH values

Evidence Based Practice:


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o Pushing with Epiduralso 7 RCTS of initial period of passive descent (laboring down )

vs. immediate pushing in primigravidas with epidurals foundthat passive descent

Increased incidence of spontaneous birth Reduced risk of instrument-assisted delivery Decreased active pushing time No change in cesarean section rate

Practical Application:

o Honor the lull phase: time between complete dilation and theonset of spontaneous bearing down efforts

o Support and encouragement of the natural bearing down process o With epidural: laboring down

Cardinal Movements

1. Descent2. Flexion3. Internal rotation4. Extension5. Restitution6. External rotation7. Expulsion

A,B= descentC= internal rotationD= extensionE= external rotation


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1. DESCENT


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4. EXTENSION

EXTENSION CONTINUES: CROWNING


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5. RESTITUTION

6. EXTERNAL ROTATION


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7. EXPULSION

Nursing Care During Birth

o Assess maternal status (VS, fatigue, coping)


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o Assess fetal status (FHR q 5-15 min) o Environment (calm, quiet for relaxation) o Encouragement/information (mirror, touch) o Positioning (upright positions) o Intake/output o Perineal care

Episiotomy

o There is no evidence to support routine episiotomy or aggressiveperineal massage at birth


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Background

o Routine episiotomy o One of the most common OB procedures o 60% of births in 1979 o 24.5% in 2004 o Initial rationale:

Shorten second stage Reduce risk of perineal trauma and subsequent pelvic

floor dysfunction o The management of the perineum during second stage is

individualized and provider specific.o Providers include doctors and midwives range from doing

nothing to supporting the perineum to aggressive massageand episiotomy

o The focus should be to prevent tearing and genital tracttrauma and increase the womans satisfaction and comfort.

o According to some studies, when performed judiciously, theepisiotomy could be below 15% of all vaginal births in the US.

o Benchmark episiotomy rates of 2% or less have been

reported in large studies of American women withphysiologic care. o Research reports that theres no need for a routine

episiotomy. There can, however, be some very specificcircumstance when it may be indicated. These indicationsmight be the following:

Extensive vaginal tearing appears likely, abnormal fetalposition or the baby needs to be delivered quickly

o Indicationso Prolonged low FHR, resistant perineum

o Complicationso Pain, infection, hematoma

o Types of Episiotomyo Median and Mediolaternal


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MIDLINE EPISIOTOM Y

Evidence Based


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Practice: Episiotomy

o Episiotomy is associated with increased: o Third and fourth degree lacerations o Pain o Healing complications

Evidence Based Practice: Perineal Massage

o Antenatal perineal massage o Decreases lacerations requiring suturing in primiparous

women o Reduces need for episiotomy o Decreases perineal pain postpartum

o Perineal massage at birth o No difference in perineal trauma

Birth Maneuvers: Practical Application

o Avoid episiotomy o Support antenatal perineal massage o Hands off the perineum at birth

Delayed cord clamping improves neonatal outcomeso Background:

o Immediate cord clamping is routine in most institutions o The timing of cord clamping affects amount of blood the

newborn receives o What is the optimum timing for the neonate?

o Evidence Based Practice: o Meta-analysis (15 RCTs and non-RCTs, n=1912) compared

late cord clamping (delayed at least two minutes) toimmediate cord clamping

o Late cord clamping: Improved newborn hematocrit Reduced risk of newborn anemia Benefits extend several months into infancy Increased benign polycythemia


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Forceps Delivery

o Types o

Low forceps preferred o Nursing Actions

o Empty bladder; lithotomy position o Monitor FHR o Monitor contractions

o Potential Complications o Maternal

Vaginal or cervical lacerations Urinary retention postpartum

o Fetal Infant bruising/abrasions at site of forcep application Brachial palsy Subdural hematoma Rare: skull fracture/intracranial hemorrhage

o Indications for use: o Prolonged 2 nd stage,

maternal exhaustion,

fetal distress, fetalmalpresentations,cardiacdecompensation

o From 1997-2008: The useof forceps to aid deliverydeclined by 32 percent,from 14 percent to 10percent


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Vacuum Extractor

Anesthesia for Delivery

1. Pudendal Provides light anesthesia on peri

neum; used just prior to delivery,anesthetizes pudendal nerves, doneintravaginally; TAKES AWAY BEARING DOWNSENSATION

Indications for use:

o Prolonged second stage o maternal exhaustion o fetal distress o fetal malpresentations o cardiac decompensation

Nursing Actions o Lithotomy position o Monitor FHR

Potential Complications o Maternal

Perineal, vaginal, cervicallacerations

o Infant Trauma at site (scalp

laceration Cephalohematoma


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2. Local

3. Paracervical 4. Spinalo Rare o Fetal bradycardia

5. Generalo Used primarily for emergency C/S o High risk of fetal respiratory depression o Risk of maternal aspiration o Systemic o

Used mostly for emergency cesarean deliveries or complications ofdelivery o Risks:

o High risk of fetal respiratory depression o Most general anesthetics reach the fetus in about two

minutes o So, not usually used with high risk fetuses, such as preterm

infants if possible o Most general anesthetics may also cause vomiting and

aspiration

Nursing Care for W omen Receiving Anesthesia

Perineum is injectedwith lidocaine

Used primarily for c-sections

Lasts up to 6 hrs Usually requires woman to

lie flat for several hours to


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During the process of rapid induction of anesthesia, the nurseapplies cricoid pressure to occlude the esophagus and preventpossible aspiration; the esophagus is occluded by depressingthe cricoid cartilage 2-3 cm posteriorly and maintained untilthe anesthesiologist has placed the endotracheal tube

1. Assist with Positioning

2. Assess Pain/Effectiveness of Treatment3. Assess VS & FHR

Trying to rule out maternal hypotension, respiratorydepression

4. Assess Intake/Output5. Assess sensation level/ability to move legs

6.

Ongoing positioning Watch positioning; no prolonged pressure on anesthetizedpart-pillow between legs

Third Stage of Labor

o Definition: Begins with birth of infant; ends with delivery ofplacenta

o Usually 5-30 minutes; because of decreased uterine surface area-placenta separates

o 2 Phases o Placental separation o Placental expulsion


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Types of Placental Deliveryo Spontaneous

o Schultz mechanism o Duncan mechanism

o Manual extraction

Evidence Based Care: Active Management of 3 rd Stage Labor

1. Administration of oxytocic agent prior to placental delivery

2.

Early clamping and cutting of the umbilical cord 3. Application of controlled traction to the cord Results in -

o Reduced maternal blood loss o Reduced cases of postpartum hemorrhage o Lower incidence of prolonged 3 rd stage of labor o Disadvantages: increased n/v, elevated BP with certain medications,

pain

Third Stage of Labor: Emotional Responses

o Joy, relief, fatigue, eager to share news o Grief work

o Loss of pregnancy as valued object o Loss of valued status as pregnant woman o Possible sense of failure


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Not achieving own expectation for labor and birth o Loss of some aspects of self (altered body image, self

esteem, changed self concept, loss of former role) o Nursing Actions

o Early infant contact ASAP on mothers abdomen if notcontraindicated

o Encourage touching/hold of infant o Keep baby skin to skin with warm blankets over both of them o Initiate breast feeding soon after birth (good for mom and

baby) o Monitor fundal height of uterus/bleeding

Monitor firmness of uterus and vaginal bleeding EBL


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o Monitor urine output; encourage bladder emptying o Comfort measures

Blankets, hydration, pain meds, ice to perineum Calm quit enviornment

FUNDAL PALPATION Suggested method of palpating the fundus of the uterus

during the 4th

stage The left hand is placed just above the symphysis pubis andgentle downward pressure is exerted

The right hand is cupped around the uterine fundus


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Lie


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= The relationship between the long axis of the fetus and the longaxis of the mother

o Longitudinal line- fetus is lengthwise or vertical o Transverse lie- fetus is horizontal

Presenting Part = The part of the fetus that lies closest to the internal os of the

cervix

Station = The relationship of the presenting part of the fetus to the

imaginary line between the ischial spines of the pelvis

One Station- The presenting part of the fetus is 1 cm past theimaginary line (0 station) between the ischial spines

The Order of Cardinal Movements of Labor and Birth 1. Descent2. Flexion3. Internal Rotation4. Extension

5.

Restitution6. External Rotation and Expulsion

LOA Left occiput anterior

o Fetal occiptal lobe is facing anteriorly and left of the maternalpelvis

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Ob Study Gizzude #3