Maternal-Newborn Nursing - Exam 1 Already Passed. when you're pregnant - intrapartum - vagina increases --> everything else squished urinary meatus - swollen - urinary retention pressure on bladder - need to pee pressure on bowels - constipation uterus - -ligaments help hold uterus in place -needs to be thick & strong to propel baby out -uterus is very viscous and vascular -fundus = the top of the uterus -plug of mucus plugs the cervix during pregnancy to make sure the baby is safe, secure, separate from vagina. This mucus plug is not there when not pregnant. -most of the pain of labor is of the cervix opening. It needs to thin and create an opening. uterus muscle layers - outer layer - longitudinal -*helps propel fetus* downward middle layer -figure 8 -contract, help to close off uterine arteries to help *stop bleeding* after birth inner layer -circular -keep cervix closed -need to pull up & out to *open/dilate cervix* to allow passage of fetus -prevents back flow of menstrual blood the muscles of the pelvic floor - -suport pelvic organs -can be weakened or damages during childbirth -can have urinary or fecal incontinence if damaged uterus --- round and uterosacral ligaments - Stretch as uterus rises in pelvic cavity "Round ligaments" -attach on sides of uterus -insert on sides of labia majora (inguinal area) -can hurt front of woman if she gets up too quickly utterosacral ligament - back pain
Factors affecting labor - the five P's - Passenger (fetal presentation, lie, attitude, position) the baby (size, shape, position) Passageway (pelvis) Powers (primary and secondary) - primary are involuntary contractions, secondary are voluntary contractions/mom's pushing efforts Positions (of the mom during labor and delivery) Psyche (where's mom's head???) Passenger - fetal head: size, shape - -open sutures and fontanelles allow bones to mold/adapt to pelvic -you could have a mom with a baby whose head is too big for her pelvis -biparietal (side-to-side) & anterioposterior (front -to-back) skull measurements important Passenger - fetal presentation: part that enters inlet first - *cephalic (head first)*: the usual presentation, 96% of babies four types of cephalic.... *vertex: complete flexion* - best way to fit through pelvis!! -head can elongate -smallest part of head presented through birth canal (like person turning body to get through crowd) military - moderate flexion brow - poor flexion (extension) face - full extension - baby comes out with bruised face as it loses its flexion, it presents increase diameters. fetal presentation - breech - only 3% of births feet first baby's head can get stuck after body comes out can be born like this but almost no Drs will deliver a breech baby now b/c we have c/s option which is much safer fetal presentation - shoulder - only 1% of births *not consistent with vaginal delivery* r/t trauma, lack of fetal reserve, decreased oxygenation can't be born this way vaginally, won't fit
fetal "lie": relation of fetus to mom - "longitudinal" - baby is vertical - cephalic or breech presentations "transverse" - baby is side-to-side/horizontal - incompatible SVD (need intervention) "oblique" - fetus at angle (btw. two) cannot deliver vaginally fetal "attitude": posture of baby - NORMAL: "flexion" (baby is all tucked up and has its limbs tucked snugly into itself) back of fetus rounded chin flexed to chest thighs flexed on abdomen legs flexed at knees arms cross over thorax ABNORMAL: extension -associated with prolonged labor -e.g., head extended, right arm extended fetal "position" - Relation of fetal presenting part to one of maternal pelvic quadrants occiput: posterior of fetal head below posterior fontanelle (i.e., BACK OF HEAD) sacrum: buttocks Is presenting part directed toward the mother's front, back, or side? (anterior (A), posterior (P), or transverse (T)) occiput anterior - back of head facing towards front of mom - easier way to be born occiput posterior - "sunny side up" baby's head pushes against mom's spine and symphysis pubis...painful for mom, baby's face can also get bruised fetal position steps - What is fetal presenting part? (middle initial) occiput [head first] (O) or sacrum [butt first] (S) 2) Is fetal presenting part to right (R) or left (L) of pelvis? (first initial) 3) Is presenting part anterior (A), posterior (P), or transverse (T) ? (third initial) most start out as LOT then rotate to LOA Passageway - the maternal pelvis and soft tissue - "True pelvis": curved, cylindrical pathway with (3 "planes"): 1) inlet
2) mid-pelvis - transverse diameter b/w ischial spines - can block the way - babies can get stuck here 3) outlet - pubic arch should be > or = 90 degrees so fetus can pass under, coccyx slightly mobile Cartilage b/w sacroiliac joint and symphysis pubis softens at term associated with "relaxin" (a hormone) passageway - pelvic types - *gynecoid* - most women (50%) - round, the ideal for childbearing; ischial spines far apart; good for big babies android - heart shaped, more like man's pelvis platypelloid - flat - like platypus's bill anthropoid - oval, favors posterior fetal position, most common in non-white races powers - primary power: involuntary uterine contractions - Originate in "pacemaker" points of upper uterine musculature Move downward in "waves"/separated by rest period Described by: - frequency- from beg. of one ctx. to beg. of next - duration- length - intensity- strength Responsible for: - *cervical effacement*: *shortening and thinning* of cervix (first stage of labor) 2-3 cm long and 1 cm thick to a "thin edge" measured 0 to 100% - *cervical dilation*: enlargement, widening/*opening of cervix* under 1cm to 10 cm (shouldn't push until 10 cm dilated...will cause swelling of cervix) uterine contractions: -fundus of uterus contracts in downward motion -muscles in lower uterus are pulled upward -contractions cause dilation and effacement in less time in a multigravida (mom who has delivered before is more likely to have a shorter labor) intensity of involuntary contractions best assessed by ______ - palpation of the fundus (mild, moderate, strong)
powers - secondary power: maternal pushing efforts - -Do not impact effacement or dilation -Vital for expulsion of infant in with uterine contractions (push WITH contraction, not after it) -Maternal involuntary "urge to push" (Ferguson reflex) TOTAL POWER=Primary power + secondary power (uterine ctx.) (mom's pushing) position - for labor - don't want them lying down, upright is best...Upright positions promote fetal descent, stronger contractions,, increased C.O. and uteroplacental blood flow Impact anatomic / physiologic adaptations to labor *Position change every hour* recommended Occiput Posterior - Interventions - used to remove pressure from mom's back can use birthing ball with back massage, pillow in between legs when sleeping on side, etc Supine hypotension - lying flat pushes uterus onto vessels (+ from the pressure of the contractions) --> hypotension decrease in mom' BP = decrease in blood flow to baby don't want to lie directly on back during labor. need to at least be tilted with a pillow. placing a *pillow under mother's right hip* (so lying on left side) decreases pressure alternative birthing positions - birthing ball -rock back and forth on ball -nursing supervision needed! -more active than lying down -encourages frequent position changes -widens pelvis and enhances fetal descent hydrotherapy -warmth and buoyancy of water relieves muscle tension -decreases pain sensations, decreases anxiety -*better if active labor* (> 5 cm) to prevent slowing of labor!! *can slow labor down* if in tub too early. -temp not above body temperature -limit time to 1-2 hours -hydrotherapy good for labor but not for delivery positions - delivery - lithotomy used to be the most common. that's like the position people do at the ob/gyn office.
now the most common is *semirecumbant*. Semi-recumbent requires body/ leg support to push effectively (hold legs-esp. if epidural). Need people to hold woman's legs. *Kneeling or squatting* position is the *ideal* position to be in. Increases pelvic outlet/facilitates 2nd stage of labor. positions that help "tip" the fetus away from the back: - Side lying (left lateral Sims): Fetus posterior*** Shoulder dystocia*** (head comes out, shoulder is caught) May increase maternal comfort May relax perineum, decrease need for episiotomies Hands and Knees: Fetus posterior*** (may facilitate rotation) Shoulder dystocia *** May relieve back labor discomfort Decreases pressure on perineum Increase blood flow during episode of fetal stress alternative : water birth - baby needs stimulation of cold, cruel world to breathe. results in floppy babies water good for labor but not for delivery Psyche - nursing role - support, decrease anxiety/pain/fear, promote sense of control Anxiety/ fear: increases catecholamines, decreases effectiveness of uterine contractility and placental blood flow, magnifies pain perception Cultural impact of: expectations responses values rituals modesty issues support persons / power issues (decision-making r.e. pain medication, consent for procedures, operative birth, etc.) Reality of expectations The processes of labor - 4 stages FIRST stage (phase one, phase two, phrase three) SECOND stage THIRD stage FOURTH stage
**cardinal movements** signs of preceding labor - Lightening (dropping of fetus into "true" pelvis) -baby moves down, mom feels like she can breathe better (since baby no longer up against diaphragm/lungs) Return of urinary frequency -baby drops down from diaphragm onto bladder Backache -ligaments in back will be stretched Stronger Braxton Hicks contractions -like practice contractions to prepare body for labor, feel like menstrual cramps Surge of energy / "nesting" -getting ready for the baby Increased vaginal discharge / bloody show -bloody show looks like spotting; should call Dr., could have ruptured her membranes Cervical ripening (may begin to efface/ dilate) -cervix starts to soften Membranes may rupture -can be dramatic puddle or a slow leak. Sometimes happens before labor, sometimes not until you're well into labor Diarrhea / GI disturbance -large intestine takes up room near baby, tries to clear itself onset of "true" labor - Signs: -consistent pattern of ctx. with *increasing frequency, duration, intensity* REGARDLESS OF ACTIVITY -lower back to abdomen pain (can be in front, back, or all around) -effacement and dilation noted Many factors involved: -change in maternal progesterone/ estrogen ratio *decreased progesterone and increased estrogen prior to delivery* -increased maternal and fetal *oxytocin* production -increased cortisol by fetal adrenal gland (uterine stimulant) / in turn stimulates *increased prostaglandin* production by decidua -increased myometrial irritability related to intrauterine pressure, stretching, aging placenta
first stage of labor: onset of contractions to 10 cm dilated/100% effacement (thinned out) all about *effacing/thinning and dilating* 1) Latent phase (0-3 cm dilated) -contractions mild, irregular q 3-30 minutes, last 30-40 seconds -*longest* of the three phases, may pass unnoticed -most people are home -times in this phase much longer for first time moms 2) Active phase (4-7 cm dilated) -moderate-strong contractions q 2-5 min, last 40-60 seconds - in a pattern -contractions increase in frequency & intensity, discomfort greatly increases -mom feels like she needs assistance and goes to hospital 3) Transition phase (8-10 cm dilated) -very strong contractions q 1-2 min, last 60-90 seconds -*shortest*, intense phase, often "urge to push" (Ferguson reflex) at end second stage of labor: from full dilation to birth of fetus (PUSHING STAGE) - all about the PUSHING. May be a "lull" or quiet period between transition and pushing when ctx. space out and become not so intense first time moms usually push about 1-2 hours, parous moms 5-30 min "prolonged" pushing >2 hr for primip >1 hr for multip BUT if progressive descent and no fetal distress then no need for forceps or c/s -lots of pain b/c perineal stretching, distention, pressure -frequently strong urge to push (Ferguson reflex) -voluntary maternal pushing efforts needed with uterine contractions "crowning" of head signifies birth imminent third stage of labor: from birth of fetus until placenta delivered - -usually 5-10 minutes after birth considered "retained" if still in mom over 30 minutes after birth ... GENTLE traction & pressure on fundus may be needed -accompanied by uterine contractions to expel placenta -SIGNS: gush of blood, cord lengthens, fundus rises (needs to contract so woman doesn't bleed from placental site)
fetal (shiny) side usually presents first "shiny sheltie" maternal side presents "dirty duncan" placenta needs to be examined to make sure there are no fragments left in mom. fragments can prevent uterus from contracting properly and promote postpartum hemorrhage. fourth stage of labor: about 1-4 hours after delivery - Blood loss + Redistribution of placental circulation = moderate drop in blood pressure, tachycardia Recovery stage make sure BP is okay. all of the blood from the placenta goes back into her system, could cause HR -Hemorrhage risk -Pain -Perineal trauma - swelling -Bladder hypotonia - can cause urinary retention -Thirst / Hunger - need to start off light -Uncontrollable shaking "chill" r/t hormonal changes...can use blanket warmer cardinal movements - first three movements (happen together/as a grouping) *Engagement*: initial movement of fetus into "true pelvis" (baby does down into true pelvis and reaches ischial spine) "lightening" or "dropping" biparietal diameter of presenting part reaches maternal ischial spines "0" station - "FULLY ENGAGED" - head has reached ischial spine *Flexion*: fetal head "nods" toward chest (smallest diameter enters pelvis) *Descent*: continued movement of fetus (often in occiput transverse position) measured by "station" - position relative to imaginary line drawn between ischial spines 0 station = head has reached ischial spine +4 or +5 = we can see the head!! ready to be born above ischial spine "negative" stations below ischial spine "positive" stations (think how it's positive to be born) cardinal movements after the first three (engagement, flexion, decent).... - happen in particular order: *Internal rotation*: fetus rotates (most commonly) from occiput transverse to occiput anterior (sometimes posterior)
*Extension*: Head moves out of flexion and alignment with body to enable fetal head to pass under symphysis pubis *Restitution*: realignment of head with body after head pops out of vagina *External rotation*: -shoulders descend and fetus rotates to transverse -usually anterior shoulder descends 1st, rotates to mid-line to deliver under symphysis pubis *Expulsion*: birth attendant lifts head and shoulders of infant toward mother's pubic bone and remainder of infant born pain in labor - PAIN = increased fear/ anxiety causes DECREASED FETAL OXYGENATION AND WASTE REMOVAL AND PROLONGED LABOR types of pain in childbirth - First Stage of Labor (dilation and effacement) *"visceral pain"* prominent in lower abdomen r/t cervical changes, distension of lower uterus, tissue ischemia pain usually only with ctx. back pain may be continuous pain may be "referred" (might start in abdomen but be referred to back) Second Stage of Labor *"somatic pain"* prominent from stretching, distension of perineal tissues, pelvic floor, traction and pressure from presenting part Quality: more intense, sharp, burning, well-localized Third Stage of Labor (similar to pain of first stage) pain management - drugs - Sedative Hypnotics -Facilitate therapeutic sleep lets patient sleep to recover a bit -anti-anxiety/help n/v Common Types Used: Histamine-1 Receptor agonists (Antihistamines) *Phenergan* (Promethazine)
IM (or IV diluted with 10-20cc of NS and given over 10-15 minutes) - *IV PUSH ONLY SLOWLY PER PROTOCOL* Sedative/ decreases anxiety and N+V *Vistaril* (Hydroxyzine) IM/ Z-track - *NO IV ADMIN* Sedative/ decreases anxiety, itching, N+V pharmacological methods of pain relief: May directly or indirectly affect fetus May slow labor (most pain meds relax smooth muscle but you need muscles to contract for labor contractions) Potential for complications increased r/t physiological adaptations of pregnancy systemic pain relief - Opioids (don't give them opioids if they want to be alert!!!) advantage: fast acting, predictable duration disadvantage: decreased LOC commonly used: -*fentanyl* -nubain -stadol nubain and stadol are NOT FOR OPIOID DEPENDENT WOMEN...can predicate withdrawal b/c they have both against and antagonist effects common s/e: *respiratory depression* (esp. in infant) -inject at beginning of contraction to lessen fetal impact Narcotic antagonist: Nalaxone (*Narcan*)... in case somebody reacts negatively -should be available in both mom and baby doses (b/c if we give opioids to mom too close to birth, baby will be "snowed," might need narcan. Need baby alert neurologically so they can be stimulated to take first breath) regional pain relief - Directed at relieving pain below level of spinal cord where inserted by decreasing nerve impulses May be analgesia or anesthesia Major benefits: - pain relief with *no alteration in consciousness*, mother may actively participate in birth -*less impact on fetus* (any effects secondary to maternal effects not directly from drugs) epidural most common spinal
puncture dura mater. can cause spinal fluid leak --> can cause spinal h/a. epidural - inject opioid in epidural space. Can turn epidural into spinal by doing through dura mater on purpose to make it a spinal. Regional pain relief - Epidural - local anesthetic + opioid (preservative free *fentanyl* or morphine) injected into epidural space pain relief/moderate loss of sedation (cannot ambulate unless only small does of opioid used) decreased feeling/sensation below level of epidural contraindications: coagulation defects, uncorrected hypovolemia, allergy potential adverse effects: -***maternal hypotension*** -prolonged 2nd stage of labor (decreased urge to push) -catheter migration/back soreness -slight fever (unrelated to infection) DANGER of maternal hypotension & poor placental perfusion s/s: maternal hypotension fetal bradycardia decreased retail variability (fetus is not being oxygenated well) interventions: -turn mom to left lateral position -increase non-additive IV per protocol (LR, D5 1/2, D5) -O2 10 L/min -elevate legs -notify anesthesiologist -vasopressor (ephedrine) if needed -monitor until stable Epidural - nursing care: -*Bolus patient with 1000 mL fluid* prior to procedure (to help prevent hypotension) -continuous IV fluids -assist birth attendant during procedure, assist holding pt -frequent *bladder assessment* (and catheterize as needed)...they can't feel when they have to pee -frequent *V/S (esp. BP)*
-*safety precautions* r/t decreased sensation -observe for s/s of adverse reactions/ s/e potential s/e of opioid analgesics: -respiratory depression (observe for 24 hr) -itching (benadryl) -n/v (phenergan) Placement: -Epidural space entered a L3-L4 , and catheter threaded -Test dose given to check placement , then therapeutic dose -Infusion can be continuous or intermittent (catheter stays in place) Regional pain relief - Spinal - -Local anesthetic injected into subarachnoid space -Complete sensory/motor function lost below level of block -Only used immediately prior to delivery, not during labor -Quicker than epidural for emergency C/S when no epidural -Contraindications and nursing care similar Potential side effect: positional headache from leakage of spinal fluid requiring a "blood patch" spinal h/a is worse when upright interventions: -caffeine -lying flat if interventions unsuccessful, do a blood patch Pudendal block - -Pudendal nerves near ischial spines injected with local anesthetic (delay follows onset of numbness) -Anesthetizes lower vagina/perineum *for episiotomy* and vaginal birth -Does not impact pain from contractions! General anesthesia - Only used as last resort r/t ***Infant respiratory depression*** not seen unless it's an emergency indications: -if contraindications to spinal or epidural -EMERGENCY c/s -extreme anxiety -a short-acting barbiturate for unconsciousness -muscle relaxant for easier intubation -anesthesia usually by face mask
a nurse may *assist during intubation* by *applying pressure to cricoid cartilage* pregnant women have increased risk for aspirating baby would also be knocked out, need to be resuscitated when born added recovery concerns: -maintenance of airway -cardiopulmonary function Local infiltration anesthesia - Used for episiotomy, laceration repair Injected locally, onset of numbness awaited, then repair Side effects are rare Nitrous oxide - Blend of 50% oxygen/ 50% nitrous oxide Self-administered by the woman via a face mask Not a strong analgesic but decreases pain perception Benefits: Simple to administer Does not adversely effect labor progress Risks: Sedation Dizziness N/v Used by 50-60% women in: Canada, UK, Australia, Finland ***MORE RESEARCH NEEDED*** non-pharmacological pain relief - "Gate Control Theory" - non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain. "Gates" in dorsal spinal cord control pain impulses to brain If "large-diameter" fibers in skin are stimulated, "small-diameter" sensory fibers are blocked (the "gate" is closed along pathway to brain) Impulses from brain originating from auditory and/or visual stimuli are also believed to impede transmission
Lamaze - partner coaches distraction techniques key Bradley method - partner coaches relaxation birth plan (low tech) Hypobirthing - partner assists reach state of calm relaxation trust birth and release fear pain relief - hydrotherapy - cautions required!! benefit: relaxation, nipple stimulation increases oxytocin safety risks: hyperthermia or hypothermia (decreased O2 to fetus), dehydration, infection from tub, fall risk (getting in/out of tub) breathing techniques - first level (early labor) do *slow paced breathing* to help them relax and be calm second level (active labor/transition) do *modified paced breathing* (x2 normal rate) and *patterned-paced breathing* (transition) ex: hee hee hoo distracts from pain breathing to stall pushing - short "pant-pant-blow" or "puff" breathing to distract and prevent them from pushing we want ___ glottis pushing - OPEN glottis pushing is recommended closed glottis -valsalva maneuver -most commonly seen -deep breath then push as long as possible -decrease O2 to baby, increased risk of perineal trauma open glottis pushing -recommended! -short pushed (5-7 seconds) or less as woman exhales - and several breaths b/w pushes -better oxygenation L& D admission assessment - Questions to assess "immediate" risk:
*Leaking fluid ?? (since when)* -amniotic fluid, rupture of membranes? *Due date ?? (EDD/ LMP)* Other important data: Contraction pattern (frequency, duration, intensity) Smoking, drug, alcohol abuse History of current pregnancy OB history Significant medical history -Allergies -Blood type -GBS (need 2 doses of penicillin before delivery if +), HepB (immunoglobulin to baby is +), Rubella false vs true labor - False: Irregular Braxton-Hicks Contractions Short duration Intensity and frequency does not increase Increased activity may decrease or stop contractions *No cervical change* True: Regular pattern Duration increases Intensity and frequency increases Increased activity does not alter contraction pattern *Cervical change* Baseline physical assessment - Vaginal exam - rule out immanent birth - determine if "true" labor / progress in "true" labor
-sterile gloves used and soluble gel unless Nitrazine test (tests for rupture of membranes/if it's pee or amniotic fluid...if it's alkaline you have ROM) alternative to Nitrazine test: Fern test....fern pattern of amnio. fluid seen under microscope, used in poorly funded hospitals who can't afford Nitrazine test -index and middle fingers inserted into vagina -assess: cervix - dilation, effacement presenting part - position, station (descent) membranes - intact, bulging, or ruptured/fluid color, clarity, odor Leopold's Maneuver's - information about fetal position -**maneuvers 1-3 stand beside woman/facing her head*** Fetal assessment - reassurance of fetal well-being General maternal systems assessment and V/S Leopold's Maneuvers - - information about fetal position -Leopold's confirm position of fetal back and facilitates location of PMI -**maneuvers 1-3 stand beside woman/facing her head*** 1st Maneuver Palpate fundus purpose: distinguish between cephalic and breech presentation (will feel baby's bottom at fundus if cephalic) 2nd Maneuver One hand steady, palpate on other side of fetus / then rpt. with opposite side purpose: determine which side is the fetal back (so we can put fetal HR monitor on baby's back, across from heart) 3rd Maneuver Palpate suprapubic area purpose: confirms presentation (will feel head if in cephalic presentation) 4th Maneuver **Face feet** Slide hands down either side of fetus (feel for little notch on back of head to see if baby's head is flexed or extended) purpose: determine whether head flexed (vertex) or extended (face) PMI, FHR - Vertex Presentations - FHR's *below mother's umbilicus* in right or left abdominal quadrant - lower, near head
Breech Presentation - FHR's usually *above umbilicus* - higher up, near head FHR Closer to mid-line as fetus descends/rotates On-going Assessments of Woman in Labor - Uterine ctx./ FHR 1st stage: continuous OR q 30m. 2nd Stage: *(cont. or q5-15m.)* Vital signs 1st stage: (B.P., pulse, respirations) q30 -60 min. Temp q 4h. - ***Temp hourly if ROM*** 2nd Stage: *vitals q 5-15 min* Vaginal exams with significant changes (limited once ROM b/c each time introduces bacteria) other assessments: Amniotic fluid assessment - PROM significant - sh/ be clear (not green or cloudy) - *monitor FHR for at least 1 minute following SROM or amniotomy* Q 2h. assess of voiding/ check for bladder distension/ dip urine (a full bladder can get in way of baby coming out) Continual pain assessment do to mom after birth - manage uterus vigorously to get it to contract so she doesn't hemorrhage GTPAL - G - Gravida # of pregnancies T - Term # of infants delivered 37 weeks or beyond P - Preterm # of infants delivered 20 to before 37 completed weeks A - Abortion # of pregnancies before 20 weeks L - Living # of living children G __ P___ - Gravida # of pregnancies regardless of duration Primigravida Multigravida (2 or more)
Nulligravida Para # of pregnancies delivered at 20 weeks or greater Primipara "primip" Multipara- "multip" (2 or more) Nullipara A woman is seen for the first time in her 2nd trimester. She reports her obstetrical history as follows: twins born at 39 weeks, and another baby on his due date, a baby born at 30 weeks, and 2 miscarriages at 10 and 12 weeks. What is this woman's gravida, para, and TPAL ? - G - 6 PT P A L