Maternal Newborn Nursing Labor Delivery Care Unit 3

Maternal & Newborn Nursing Labor & Delivery Care Unit 3

Descent Terms • Engagement –fetal head passes the mother’s ischial spines – Stations; -3 to +3 • Descent – progress of the presenting part through the pelvis • Flexion – fetus’s chin lays against its chest

Descent Terms (cont) • Extension – process in which contractions push the fetal head under the lower border of the symphysis pubis – 1 st the occiput, then face, then chin • External rotation – baby rotates from anterior position back to transverse position – Anterior shoulder, posterior shoulder, full body – Considered time of birth

Local Infiltration • Anesthetizes perineum • Contractions felt • Assess perineal edema, trauma, allergic reaction

Epidural Block • Anesthetizes umbilicus to thighs • Contractions not felt, may slow labor • Assess maternal BP & P every 15 min. , maternal bladder frequently, orthostatic hypotension, FHR, infection, allergic reaction • Should not ambulate

General Anesthesia • No contractions felt • Aspiration risk • Complete relaxation may lead to excessive uterine bleeding • May depress maternal &/or neonates resp.

Fetal Monitoring • Information is associated with fetal oxygenation • Types – External • Noninvasive, used at any time • Obesity, maternal/fetal movement & fetal position may affect quality • Straps may be uncomfortable

Fetal Monitoring: Type (cont) • Internal – Minimal artifacts – Abnormal FHR recordings more easily recognized – Membranes must be ruptured & cervix dilated to 3 -4 cm – Degree of risk of fetal/maternal infection – Improperly placed electrode or catheter could injure fetus or mother

Monitoring Terms • Baseline – FHR recorded between contractions over a period of at least 10 min. – Ranges 120– 160 bpm

Monitoring Terms (cont) • Baseline variability – Variation of FHR during a baseline recording – Marked variability = good fetal well being – Loss of variability or smooth baseline = fetal distress • Hypoxia

Monitoring Terms (cont) • Tachycardia – Baseline FHR > 160 bpm – Persistent may be sign of fetal distress • Bradycardia – Baseline <120 bpm

Monitoring Terms (cont) • Acceleration – Short increase in FHR above baseline – Uniform in shape; begin at same time as contraction & ends when contraction ends – Not a sign of fetal distress

Monitoring Terms (cont) • Deceleration – short term decrease in FHR • Early deceleration – “mirror” contraction; start when contraction starts & ends when contraction ends – Parasympathetic nervous system stimulation from fetal head compression – Not sign of fetal distress

Monitoring Terms (cont) • Variable deceleration – Not uniform in shape; might fall abruptly & return abruptly – FHR returns to normal by end of contraction – Most instances from umbilical cord compression & may/may not be sign of fetal distress

Monitoring Terms (cont) • Late deceleration – Begin at or after peak of contraction & return to baseline after contraction ends – Due to fetal hypoxia from uterine placental insufficiency = sign of fetal distress

Signs of Fetal Distress • Persistent tachycardia > 160 bpm • Severe variable or late decelerations that persist in spite of maternal position changes • Loss of baseline variability

Signs of Fetal Distress (cont) • Meconium in amniotic fluid • Irregular FHR • FHR < 100 bpm during a contraction & not return to normal 10 – 15 seconds after contraction ends

Nursing Interventions • Change mother’s position, preferably to left side – vena cavae on right side = blood flow to mother & uterus • Decrease uterine activity • O₂ • Correct mother’s hypotension = position left side with legs up 30 degrees

Inducing Labor • Amniotomy – Artificial rupture of membranes – Causes presenting part to exert greater pressure on the cervix = stronger contractions

Inducing Labor (cont) • Oxytocin administration – IV induction of hormones used to initiate & sustain uterine contractions

Inducing Labor (cont) • Prerequisites – At or near term with mature fetus – Cervix soft with moderate amt. effacement & dilation – No CPD – Fetal head fixed in inlet

Inducing Labor (cont) • Nursing interventions – Explain procedure – Record FHR – Assess amniotic fluid – VS, intensity & frequency of contractions

Labor & Contraction Terms • Vaginal exam – Manual exam of vagina & cervix • Fetal heart rate or tone – Per fetal monitor or fetoscope; 120 – 160 bpm

Labor & Contraction Terms (cont) • Dilation – Stretching of the external os; few cm to 10 cm • Effacement – Thinning & shortening of cervix; 50 – 100%

Labor & Contraction Terms (cont) • Position – Relation of an arbitrarily chosen fetal reference point to its location in the maternal pelvis – Ex: ROA = right occiput anterior • Presentation – Part of the fetus lowest in mother’s pelvis – Cephalic, breech, transverse, footling

Labor & Contraction Terms (cont) • Contractions – tightening or shortening of uterine muscles; intermittent & involuntary – Frequency • Determined by timing from beginning of 1 contraction to the beginning of next; noted as 3 – 5 minutes – Duration • Determined by timing contraction from its beginning to its end; noted as 45 – 50 seconds

Labor & Contraction Terms (cont) • Contractions (cont) – Intensity • Determined by placing a hand on mother’s abd. & feeling the firmness of uterus during a contraction. Noted as soft or hard.

Early Labor Signs • • Bloody show Recurrent pains in back &/or abdomen Rupture of membranes Uterine contractions gradually increasing in frequency, intensity & duration

True Labor Signs • Regular contractions increase in frequency, duration, intensity • Activity increases labor • Effacement & dilation occurs • Bloody show • Discomfort / pain radiates from back to front

False Labor Signs • • • Irregular contractions No pattern or change No progressive dilation or effacement No bloody show Discomfort centered in abdomen

Stages of Labor • 1 st stage – Period beginning with regular contractions until complete dilation of cervix • 2 nd stage – Period from complete dilation of cervix until birth of baby

Stages of Labor (cont) • 3 rd stage – Period from birth of baby to birth of placenta • 4 th stage – Period from completion of placenta delivery to postpartum condition is stabilized

Nursing Responsibilities • 1 st Stage – See handout.

Nursing Responsibilities (cont) • 2 nd stage – see handout • May be responsible also to newborn – Patent airway, stimulate respirations – Prevent aspiration – Determine APGAR • 1& 5 min assess heart rate, resp. effort, muscle tone, reflex irritability, color

Nursing Responsibilities (cont) • Newborn responsibilities (cont) – Prevent heat loss • Dry & cover infant head, place under warmer – Safe environment – ID by footprints & ID band – Vitamin K IM • Assist in blood clotting

Nursing Responsibilities (cont) • Erythromycin ointment to eyes – Prophylactic treatment • Opthalmia neonatorium (Neisseria gonorrhea) & chlamydia

Nursing Responsibilities (cont) • 3 rd stage – Assist with IV oxytocin – Documentation • Time placenta expelled & delivered Duncan (mom side) or Schultze (shiny side) • Type & condition of episiotomy • Lacerations if any & repair

Nursing Responsibilities (cont) • 4 th stage – See handout.

Precipitate Delivery • One that labor less than 3 hrs. • Nursing care – Monitor FHR – Reduce anxiety – Assist with administering anesthesia – Evaluate newborn for injury – Observe for maternal hemorrhage

Dystocia • Difficult labor d/t factor produced by fetus or the maternal pelvis or d/t inadequate uterine activity • Mechanical – Maternal – Fetal

Dystocia (cont) • Functional – uterine contractions deviate from normal – Hypertonic uterine dysfunction • Uterine muscle in greater than normal tension = contractions ineffective = no dilation – Hypotonic uterine dysfunction • Contractions inadequate

Uterine Rupture • Spontaneous or traumatic rupture of uterus • Assessment – Abd. pain during contractions – Contractions may/may not cease but no dilation – Bleeding into abd. cavity & possibly into vagina – Fetus easily palpated but no FHR – Maternal pulse increases, skin pallor, shock

Uterine Rupture (cont) • Nursing interventions – IV fluids – O 2 – Preop for emergency surgery – VS • Fetal prognosis poor • Maternal prognosis guarded

Prolapse Cord • Cord is in front of or along side of presenting part; can be seen protruding from vagina or palpated in vaginal canal or cervix • Nursing care – Trendelenberg position – O 2

Prolapse Cord (cont) • Nursing care (cont) – Place sterile gloved hand in vagina & push head upward to relieve compression. Never push back in – Prepare for immediate vaginal delivery

Breech Presentations • Footling – One or both feet present • Frank – Buttocks present & legs are extended up over abd & chest • Complete (full) – Buttocks & feet present, legs are flexed

Cephalopelvic Disproportion (CPD) • Mother’s pelvis is too small for the baby’s head is too large for the mother’s pelvis • Cesarean section will be necessary

Multiple Births • Confirmed by hearing 2 or more distinct fetal heart beats & by ultrasound • Uterine dysfunction during labor & postpartum hemorrhage not unusual • Prepare for premature birth

Episiotomy • Surgical incision made into perineum to aid in delivery of infant • Facilitates repair of vagina & perineal damage • Promotes healing • Spares infant head from prolonged pressure & pushing against rigid perineum

Episiotomy (cont) • Types – Midline • Middle of perineum toward rectum – Mediolateral • Laterally to left or right in perineum & avoids anal sphincter

Episiotomy (cont) • Nursing care – Education – Ice packs – Sitz baths – Local analgesic spray

Special Deliveries • Forcep use – Extracting of the fetal head – Mother should have empty bladder – Examine infant for facial paralysis, injury to eyes or skull, facial abrasions or bruises

Special Deliveries (cont) • Vacuum extraction – Applies suction to fetal head allowing adequate traction for delivery of infant’s head – Examine infant for scalp laceration, intracranial hemorrhage, cephalohematoma

Special Deliveries (cont) • Cesarean – removal of the infant through an incision made in the abd wall & uterus • Types – Transverse – • Transverse incision in lower segment of uterus; most preferred; maybe vaginal later – Classic • Vertical incision

Cesarean Delivery (cont) • Preop Care – Prep – Foley – FHR & contractions – Lab results • Postop Care – Same as abd surgery – Fundus – Lochia – Reassurance