Practical Nursing Series: Maternal Newborn Nursing

Transcription

1 This free sample provided by CIMC www Practical Nursing Series: Maternal Newborn Nursing Maternal Newborn Nursing adheres to the revised objectives approved by the Oklahoma Board of Nursing. This full-color text provides a basic overview of maternal and newborn care skills that the practical nursing student needs in order to be successfully employed in today s healthcare setting. Maternal Newborn Nursing is designed to teach the nursing student the basics of maternal and newborn care skills and the ability to apply their knowledge to prepare for the NCLEX-PN. Modules include: Antepartum Care Intrapartum Care Postpartum Care Newborn Care Practical Nursing: Maternal Newborn Nursing 2011 Teacher Edition: HO1035 Student Workbook: HO3035 To order, call or visit www. Copyright 2011 Oklahoma Department of Career and Technology Education

2 IM Practical Nursing Maternal Newborn Nursing Teacher Edition www CIMC HO1035

3 MODULE 2 i N T r A PA r T U M C A r E Intrapartum is the phase of pregnancy when delivery of the fetus takes place. The LPN will often be responsible for caring for patients during labor and delivery. This module is designed to outline the events that occur during normal labor and delivery, as well as some of the complications that can arise. The nurse s role in providing support for the patient and the family during labor and delivery is presented. Observing the birth of a new life is fascinating. Labor and delivery is a unique specialty as there is the responsibility for the laboring patient as well as the fetus. Responsibilities also may include family and other loved ones in attendance. Many times entire families will show up for the emotional event. The nurse is responsible for providing a professional and safe environment, and at times, must care for the family. Most hospitals require a Registered Nurse (RN) to work in labor and delivery (L&D) because this is an area of high litigation and requires a great deal of knowledge and critical thinking. Some hospitals allow practical nurses to work in the area, within their scope of practice. These skills may include limited assessment skills, monitoring patient and fetus and providing support and comfort during the birthing experience.

4 i Review the Learning Objectives with the students. Look ahead to the Learning Activities in this module and plan to introduce them. L E arni ng O bject I v E s 1. Differentiate between true labor and false labor. 2. Classify the stages and phases of labor. 3. Describe fetal physiologic responses to labor. 4. Identify nursing actions necessary when admitting a woman to the labor unit. 5. Identify the role of the practical nurse in the interpretation of: Fetopelvic relationship Fetal assessment Contractions Leopold s maneuvers Vaginal examination 6. Identify types of pain management used during labor. 7. Describe the physiological and psychological care for a patient during labor and delivery. 8. Identify potential maternal and fetal complications during labor and delivery. 9. Differentiate between induction and augmentation techniques of labor: Amniotomy Medications 10. Describe methods of delivery used during second stage of delivery: Episiotomy Forceps Vacuum extractor 11. Discuss responsibility of the LPN/LVN while caring for the mother and newborn during labor and delivery. 2 CIMC MATERNAL NEWBORN NURSING MODULE Overview Intrapartum care is the care of women and their babies during childbirth. The student will learn the intrapartum period extends from the beginning of contractions that cause cervical dilation to four hours after delivery of the newborn and placenta. The student will learn intrapartum refers to the medical and nursing care given to a pregnant woman and her family during labor and delivery. 2 CIMC MATERNAL NEWBORN NURSING

5 L E a r n I n g O b j E C t I v E Objective Identify nursing actions necessary when admitting a woman to the labor unit. The fetus is considered term at 37 weeks and can continue in the womb up to 42 weeks. At 40 weeks the fetus should be fully developed, the lungs should be fully mature and ready for life outside the womb. In the time leading up to delivery, the patient and family prepare for birth. Many times, they have dreamed, planned, read books and/or attended birthing classes. The patient arrives in labor and delivery (L&D) with expectations of the perfect birth and baby. The nurse should respect the patient s expectations while following hospital policy and procedures and maintaining the safety of the patient and the fetus. What causes labor to begin is not fully understood. However, the fluctuation of prostaglandin and estrogen levels and the stretching and thinning of the uterus are theories. Some patients get excited when they lose the mucous plug. The mucous plug is a thick yellowish piece of mucous that is located in the cervix opening. Its purpose is to prevent Typical Admission Questions Question When is your due date? When was the last time you felt the baby move? What is the GTPAL? Gravida (G) = total number of pregnancies Term (T) = number of pregnancies carried to 37 weeks Preterm (P) = number of pregnancies delivered before 37 weeks Abortions (A) = number of elective or spontaneous abortions Living (L) = number of living children at this time bacteria from entering the uterus. As the cervix softens and dilates, the plug may fall out up to two weeks before labor begins or during delivery. admission to LabO r and D ELIv E ry Nursing actions upon admission to labor and delivery include: Make patient as comfortable as possible Reviews the patient s health history and prenatal records Complete needed admission and treatment forms Take vital signs Assist with obtaining lab specimens and evaluation results Apply fetal monitor to the patient s abdomen (usually with elastic belts) There are several focused questions that are part of an intrapartum admission. This usually can be done by the RN, but some data gathering may be delegated to the LPN. This information can be helpful when assessing the progression of labor. Rationale This is important to know because the infant may need a critical care nursery if it is preterm. If the patient is past expected due date, the infant may need to be delivered. Fetal activity represents a fetus that is oxygenated and alive. The number of pregnancies is important and may help predict the pace of labor or let the nurse know of possible complications. MODULE 2 INTRAp ARTUM CARE student EDIt IOn 3 Answer: True contractions do not go away with hydration or walking. Instead, they are regular in frequency, duration and intensity, and become stronger with walking. Braxton-Hicks contractions decrease with hydration and walking. A patient experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. What is the first nursing action after establishing the fluid is amniotic fluid? Answer: Fetal heart rate must be monitored for distress. There is a high risk of umbilical cord prolapse with the rupture of membranes, and therefore, FHR is the first thing the nurse should assess once rupture of membranes has been established. ADDITIONAL CRITICAL THINKING QUESTIONS A patient at 38 weeks gestation tells the nurse that it feels like her baby is sitting on her bladder causing her to urinate frequently. However, the patient states it has made it easier for her to breathe. The nurse recognizes that this is a sign of lightening. Discuss lightening. Answer: The patient has experienced lightening, whereby the fetus drops down as it prepares to engage. This puts more pressure on the bladder but can alleviate difficulty breathing and indigestion problems. A patient reports that her contractions started about two hours ago, did not go away when she had two glasses of water and rested, and became stronger since she started walking. She thinks the contractions occur every 10 minutes and last about half a minute. She hasn t had any fluid leak from her vagina. However, she did think she saw some blood when she wiped after voiding. The patient is experiencing true contraction. The pregnant patient asks the difference between Braxton-Hicks contraction and true contraction. MODULE 2 IntrapARTUM Care TEACHER EDITION 3

6 learning www link Labor and Delivery Flashcards com/ /351-laborand-delivery-flash-cards/ Question What was the method of delivery of your previous delivery? How long was the labor and were there any complications with your last pregnancy? Have you ever had a cesarean section and why was it performed? Has your water broken? If yes, what color was it? When did it break? Are you having contractions? When did it start to become regular? What does it feel like? Is there vaginal bleeding? If so, how much and when did it start? Rationale Usually delivery is done the same as previous deliveries. The time frame of last labor may offer some indication of the length of this labor. If a patient had an emergency cesarean section, the patient may need another cesarean section. Spontaneous rupture of membranes (SROM). Green color might be caused by meconium. Meconium fluid occurs when the baby is stressed during pregnancy and could be a problem if the infant inhales it into the lungs. Special precautions are taken at birth with meconium. If the membranes are ruptured more than 24 hours, infection may occur. This is important to know because the duration and frequency of contractions are related to the amount of blood the fetus receives. Timing contractions assists in determining stages of labor. Vaginal bleeding of any amount must be investigated. Blood-tinged mucous is normal and vaginal bleeding is not. Have you ever been diagnosed with a sexually transmitted disease? Who would you like with you during labor and delivery? This is important to know because the infant passes through the vaginal canal and sexually transmitted disease (STD s) can be dangerous for the fetus. Are you allergic to latex or Betadine? Vaginal birth is contraindicated with active vaginal herpes. Many of these products used during delivery may cause allergic response. This is important due to patient s need of support during the labor and delivery process. Do you have any special requests for your labor and delivery experience? The patient has the opportunity to request mirrors, special needs during labor, and pain management. The birth plan and cultural requests can also be made at this time. 4 CIMC MATERNAL NEWBORN NURSING 4 CIMC MATERNAL NEWBORN NURSING

7 L E a r n I n g O b j E C t I v E Objective Differentiate between true labor and false labor. t r UE O r FaL s E LabO r When the assessment is completed, it must be determined if the patient is in true or false labor. This is determined by the RN in cooperation with the physician. Once the cervix starts to dilate, the patient is considered to be in true labor. The difference between true and false labor is that cervical dilation occurs with true labor. Some patients may experience Braxton- Hicks contractions (BHC). BHC s can occur during late pregnancy and feel like a tightening, mostly in the abdomen. They are usually irregular contractions and for most patients, the contractions remain the same and do not progress to regular intense contractions that cause cervical dilation. The contractions in true labor will increase in intensity and cause dilation of the cervix. Characteristics of True and False Labor Characteristic True Labor False Labor Contraction length Last longer as labor progresses Vary in length Contraction frequency More frequent as labor progresses Rarely follow a pattern Contraction strength Get stronger as labor progresses Vary in intensity Contraction location Effect of contractions on the cervix Start in the lower back and travel to the lower abdomen Effaces or dilates as labor progresses Felt mostly in the fundus May cause some softening of the cervix Effect of contractions on the Pushes the fetus downward into Does not affect fetal position fetus the pelvis The process of labor and delivery involves what is referred to as the five P s: Passageway (pelvis, cervix, and vagina) Passenger (fetus and placenta) Powers (contractions) Positions utilized by the mother Psychological factors related to pregnancy One part of the passageway is the pelvic opening. For a vaginal birth to occur, the fetal head must be able to pass through the mother s pelvic opening. The primary care provider will palpate and measure the distance between bony prominences in order to determine the shape and size of a woman s pelvis. The cartilage of the symphysis pubis softens in response to hormones and allows the pelvic bones to open somewhat during birth. Ultrasound is also used to help determine the size of the fetus and the likelihood of the head fitting through the pelvic opening. Women who have a heart-shaped pelvis or an oval pelvis are more likely to require a forceps-assisted delivery. Women with a heart-shaped pelvis may even need a cesarean delivery, depending on fetal size and pelvic size. MODULE 2 INTRAp ARTUM CARE student EDIt IOn 5 MODULE 2 IntrapARTUM Care TEACHER EDITION 5

8 Many times cesarean sections are required due to the difficulty the baby has trying to mold the head to pass through the shape of the pelvis. The size and presenting part of the fetus, the passenger, also plays a big part in a safe vaginal delivery. The most common and ideal shaped pelvis for vaginal birth is the gynecoid pelvis. Cervical dilation and effacement are part of the passageway. Pre-pregnancy the cervix is long and thick and has a tiny opening called the cervical os which is plugged with mucous to prevent microorganisms from entering the uterus. For vaginal birth to occur, the cervix must open wide enough to allow a seven or more pound, 22-inch long (average) infant to pass through it. The fibrous musculature of the cervix softens and thins (effacement) and the os opens (dilation). The term presentation refers to the part of the fetus that enters the pelvis first. The presenting part of the fetus is usually the head, referred to as cephalic presentation. The head is against the inner os of the cervix. As Braxton-Hicks contractions and labor contractions occur, the head presses against the os and surrounding musculature. This pressure causes the cervix to thin and open, which allows the passenger to be born. The descent of the fetus into the pelvis is described as station. The station of the presenting part is measured in centimeters. For example: -2,-1, zero, +1, +2. Zero station is level with the ischial spines. Minus numbers are above the ischial spines and plus numbers are below. IMPORTANT FACT: Dilation occurs with the opening of the cervical os. This opening is measured in centimeters and referred to as; fingertip- which is barely open, 1 cm, 2 cm then progresses to complete, which is 10 cm. At 10 cm, the cervix is no longer felt. The major power during labor is the contractions of the uterus. Another power is the mother pushing during the birth. Uterine contractions start at the top, or fundus, of the uterus and spread over the uterus in about 15 seconds. Then the uterus relaxes, allowing blood flow to increase again to the fetus and allowing the mother to rest. During a contraction, the nurse can place a hand on the patient s fundus and feel the firmness of the uterus. Effective contractions last up to 90 seconds and have a minimum of 60 seconds of relaxation between each contraction. If contractions last longer than this, they can compromise blood flow to the fetus. The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. When contractions are said to be three minutes apart, it means that three minutes elapse from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the length of time one contraction lasts. When uterine contractions occur, the fetal circulation is slowed during the contraction. The umbilical cord contains 2 arteries and one vein. There should be at least a minute between contractions to allow adequate fetal blood flow and oxygenation of the fetus. The position of the mother is important when contractions are occurring. When the woman lies on her back, her contractions will have less intensity, although they may be more frequent than when she uses other positions. When the mother lies on her side, her contractions are more intense, but less frequent, so labor progresses more quickly. It is best for the mother to lie on her side, since it will prevent supine hypotension syndrome (see Antepartum Care module) and it provides the best oxygenation for the fetus s tations 6 CIMC MATERNAL NEWBORN NURSING CLASSROOM ACTIVITY Obtain an OB static manikin. Demonstrate fetal attitude, lie, presentation and position. 6 CIMC MATERNAL NEWBORN NURSING

9 L E a r n I n g O b j E C t I v E s Objective Objective Objective Classify the stages and phases of labor. Differentiate between induction and augmentation techniques of labor: Amniotomy Medications Describe methods of delivery used during second stage of delivery: Episiotomy Forceps Vacuum extractor s tage s and p hase s OF LabO r First Stage The first stage of labor begins with the onset of cervix dilation 0-2 cm and ends when the cervix is completely dilated. The first stage occurs in three phases. 1. Latent phase also called the early phase. During the latent phase, the uterine contractions become regular and are mild in strength. Uterine contractions are described by frequency, duration and strength or intensity. Uterine contractions average from seconds in duration and 3-5 minutes apart in frequency. The cervix dilates from 0 cm to 4 cm. Many women arrive at the hospital with some effacement and dilation. Dilation and effacement occur during the latent phase. The fetus head becomes engaged, moving against the cervix into the pelvis. 2. Active phase The active phase begins after cervical dilation of 4 cm and continues until 8 cm. The contractions should be regular at this time and the patient s anxiety increases due to increased pain. The patient may begin to ask for pain medication or an epidural. The fetus may begin to descend and the patient needs encouragement to breathe and relax. 3. Transition phase The transition phase begins after cervical dilation of 8 cm and continues until 10 cm, known as completely dilated. This is the last and toughest phase for the patient. The urge to push is great and the cervix may not be fully dilated. The patient is instructed not to push. Uterine contractions are strong in intensity, occurring every 2-3 minutes and lasting up to seconds. The patient needs help with breathing techniques to maintain focus and control. Some patients may become frustrated and angry and have feelings of being out of control; they may beg to get it out. Encourage the patient and assure her that this phase will pass and she will be able to push soon. Second Stage The second stage of labor begins when the cervix is fully dilated, 10 cm, and ends with the birth of the baby. The patient is instructed to push and the significant other is supportive and encouraged to participate. For the patient, the urge to push is great and a relief to some. Patients may request a mirror to watch for progression; others do not want to look. Uterine contractions are at the strongest level as the fetus descends to the perineal floor. As the fetus begins to crown, the perineum stretches and becomes thin. The vaginal opening begins to open at the peak of contractions and may disappear between contractions. As the fetus progresses under the pubic arch, the opening will increase and the anus may protrude. The PCP should be present and the patient is prepped for delivery. When the head crowns, extends beyond the labia and does not go away between contractions, the PCP decides if an episiotomy is necessary. The head extends out of the vagina, next the shoulders, and then the body follows with another push. The infant cries and the umbilical cord is cut. Watch the significant others at the time of birth and encourage a seat if they become nauseated or light-headed. learning www links Stages of Labor Video us/videos-369-signs-and- Symptoms-of-Labour Transition Stage Video us/videos-372-transition 2nd Stage of Labor Video us/videos-365-second- Stage-of-Labour MODULE 2 INTRAp ARTUM CARE student EDIt IOn 7 CLASSROOM ACTIVITY Divide the students into four groups. Assign each group a stage of labor First, second, third, and fourth stage. Have the students develop a poster highlighting the signs and symptoms of their assigned stage of labor. MODULE 2 IntrapARTUM Care TEACHER EDITION 7

10 Fetal Passage Through Birth Canal Mechanism Description Stage Engagement Descent Flexion Internal rotation Extension Occurs when the fetus head or other presenting part enters the true pelvis. After engagement, the fetus head moves through the passageway as contractions occur. This is measured in centimeters above and below the ischial spine and is referred to as station. The fetus neck flexes, causing the chin to rest on the sternum so that the narrowest part of the head enters the passageway. The fetus head rotates so that occiput is next to the mother s symphysis pubis. The fetus head moves under the symphysis pubis and the neck extends as the head leaves the passageway. Before stage 1 in primigravidas and during stage 1 in multigravidas Stage 1 Stage 1 Stage 2 Stage 2 Third Stage The third stage of labor begins after the delivery of the baby and ends with the delivery of the placenta. A sample of cord blood is taken from the cord, labeled and sent to the lab by the nurse. During this time the PCP is looking for tears or clots. The shiny side of the placenta is called the Schultze mechanism. This is the side of the membrane that held the fetus. The side that attaches the placenta to the uterine wall is referred to as the Duncan mechanism. This appears as a dark roughened surface. The PCP makes sure the placenta is delivered without leaving retained placental fragments. The placenta should deliver within 30 minutes after delivery and there is usually a small gush of blood as the placenta delivers. The nurse may inject the IV bag with oxytocin to aid in the contraction of the uterus and decrease bleeding. Fourth Stage The fourth stage of labor begins after the delivery of the placenta and ends after four hours. There are many changes the patient has gone through. The physical energy required during delivery and the loss of placenta and blood volume may cause the patient to shiver at this time. Comfort and bonding with the infant are encouraged. The patient is tired and may request drink and food. This is a normal process and the nurse may hear the patient tell the birthing story repeatedly to family or friends. While this is a great time for bonding and family, the nurse is still responsible for evaluating the patient s uterus, blood flow, and vital signs and monitoring the infant. It is important to remember that this is the ideal sequence and progression of the labor stages. The experience is individual to each patient and there are many factors that can affect every labor experience. Primipara patients often deliver within 8 CIMC MATERNAL NEWBORN NURSING 8 CIMC MATERNAL NEWBORN NURSING

11 24 hours and subsequent labors are shorter. A Multipara patient s labor is on average hours and each delivery is expected to be shorter. membranes, the nurse should note the color, amount and unexpected odors. Monitor FHR and contractions closely during and after. InDUCt IOn and aug MEntatIOn OF LabO r An induction may be ordered to begin labor because labor sometimes does not begin on its own. An induction of labor is ordered for the following reasons: Oxytocin (Pitocin) is used to induce labor by generating uterine contractions. The medication is increased slowly until the uterine contractions are of adequate frequency and duration that results in cervical dilation. Oxytocin can be started during labor to strengthen contractions, which is another form of augmentation. The patient must be monitored closely with the use of oxytocin. Past due dates Fetus is large (macrosomia) PCP believes the infant should be delivered because the infant is term One way to induce labor is by artificial rupture of membranes (AROM). An amniotomy can also be done for the augmentation of labor. Augmentation is needed when the uterine contractions have decreased and/or labor has stalled or not progressed. A physician uses a sterile hook-like instrument to open the sac allowing the amniotic fluid to escape. Amniotic fluid smells salty or fleshy and should not smell foul. Foul odor or green meconium stained fluid is not expected and can mean difficulty for the fetus. A rule of thumb is that the fetus should be delivered within 24 hours after rupture of membranes to prevent infection. The fluid is assessed for color and amount. Yellowish or brownish color may indicate problems for the fetus. As soon as membranes rupture, the nurse should assess the fetal heart rate (FHR) immediately. Labor generally starts within six to eight hours. Once the membranes are ruptured, the patient will be kept in bed with bathroom privileges. Monitor FHR and contractions continuously to prevent hyperstimulation. Hyperstimulation of the uterus is contractions that are too frequent or do not rest and will cause fetal distress. Uterine contractions cause cervical dilation, but the cervix should be thin and favorable. When the cervix is not favorable, thick and hard, the cervix is prepared by ripening. Cervical ripening is done with prostaglandin agents. Prostaglandin agents such as dinoprostone (Prepidil, Cervidil) or misoprostol (Cytotec) are inserted into the cervical opening to promote cervical softening and dilation. The patients are usually brought in the night before induction and receive the cervical ripening agent. Oxytocin is started the next morning according to protocol. Occasionally uterine hyperstimulation occurs and the medication is removed or washed out. Sometimes the patient actually begins labor shortly after induction. Nursing interventions include: Have the patient empty their bladder before insertion. Instruct the patient to remain recumbent for 30 minutes after insertion. Monitor the contractions and the FHR during and after insertion. Nursing Interventions Prepare the patient by informing them of what to expect, placing them in a reclined position with the feet pulled up, and pads placed under the buttocks to collect the fluid. When the PCP ruptures the MODULE 2 INTRAp ARTUM CARE student EDIt IOn 9 MODULE 2 IntrapARTUM Care TEACHER EDITION 9

12 There may be instances when an induction, augmentation or cervical ripening is contraindicated. They may be for the following reasons: Placenta previa Breech or transverse lie presentation Previous cesarean section with a classic incision. (A classic incision is used in emergency situations and the uterus is cut vertically which causes the uterus to be more susceptible to rupture.) M E thods OF D ELIv E ry Occasionally, during the second stage of labor, the PCP has to help the fetus pass through the vaginal canal. An episiotomy may be done to allow the fetal head or shoulders to exit easily or may be done to prevent tearing of the perineum. An episiotomy is easier to repair than irregular tears. Most often the episiotomy is made midline into the perineum to prevent tearing into the rectal sphincter. The decision for an episiotomy should be discussed with the PCP before labor begins. Fetal bradycardia can be noted due to compression of the fetal head during use. Occasionally, these techniques do not work and a cesarean section is ordered for a safe delivery. After delivery the newborn s face should be examined for any signs of bruising or caput and must be documented. Nursing Interventions Obtain the needed equipment and maintain a sterile field. Record time of application. Monitor uterine contractions and inform the patient and PCP when to push because the use of forceps and/or a vacuum are used during a contraction for the best results. Monitor FHR s related to what is happening during delivery. Forceps or a vacuum extractor may be requested by the PCP for delivery. Forceps are medical instruments made of surgical steel and are used to rotate, grip or pull the fetus in a position for delivery. Station of the head must be within acceptable range or forceps and vacuum extractors are not appropriate. Forceps are applied to the sides of the fetal head and cheeks. The vacuum extractor is plastic and is applied to the top of the fetal head. Suction is increased during a contraction and released between contractions. The PCP pulls down on the handle attached to the suction cup to deliver the head. Forceps or a vacuum extractor may be required in the following situations: Helping the fetus under the pubic arch Delivering the fetus quickly due to fetal or maternal distress The patient has become exhausted and can no longer push effectively Anesthesia has affected the patient s ability to push 10 CIMC MATERNAL NEWBORN NURSING 10 CIMC MATERNAL NEWBORN NURSING

13 L E arni ng act I v I ty 1 n a ME Introduction In this activity, you will learn about ways nurses can be supportive during the labor and delivery process. You will also learn about appropriate assessments to make of the patient and ways you can support her partner. Ways to help the mother with breathing techniques during labor will also be examined. a ctivity Work in groups of five on this activity, or as directed by the facilitator. Choose one of the following topics to research and present to the group. You will become the group expert on this topic. Assessment of patient when admitted to labor and delivery Nursing care of patient during labor (Stage 1 and 2) Nursing care of patient and baby just after delivery (Stage 3 and 4) Involvement of the father or partner during labor and delivery Emotional support for the patient and partner Use three resources for research and list them. Prepare handouts or visual aids to help others in the group remember the key information in the presentation. a pplication Present your findings to the class. It will be graded using the following rubric. A Level 3 presentation will: Include complete thorough information about the nursing assessment and care of this aspect of labor Include visual aids and handouts to help learners remember the information presented Include a list of three or more references used in your research Be well-organized and completed in the time allowed MODULE 2 INTRAp ARTUM CARE student EDIt IOn 11 MODULE 2 IntrapARTUM Care TEACHER EDITION 11

14 A Level 2 presentation will: Include adequate information about the nursing assessment and care of a patient with the disorder Include visual aids or handouts to help learners remember the information presented Include a list of at least two references used in research Be fairly organized and completed within one minute of the time allowed A Level 1 presentation will: Include minimal information about nursing assessment and care of this aspect of labor Lack visual aids or handouts Include one reference used in research Lack organization and be completed in more than one minute over time NO POINTS will be awarded the presentation/learner that: Lacks accurate information about the assessment and nursing care of this aspect of labor Lacks references used in research Does not participate in the Learning Activity 12 CIMC MATERNAL NEWBORN NURSING 12 CIMC MATERNAL NEWBORN NURSING

15 L E a r n I n g O b j E C t I v E s Objective Objective Objective respo nse s and C OMp LICatIOns Describe fetal physiologic responses to labor. Identify the role of the practical nurse in the interpretation of: Fetopelvic relationship Fetal assessment Contractions Leopold s maneuvers Vaginal examination Identify potential maternal and fetal complications during labor and delivery. Fetal Physiologic Responses The fetus begins development at conception and hopefully makes it to term before delivery, when the fetus can function outside the womb. What occurs during labor and delivery is monitored closely. The following explains fetal heart rate (FHR), also called fetal heart tones (FHT). Monitoring the Fetus Electronic monitors are often used during labor to assess the fetal heart rate in response to contractions and to assess the contractions. Two different types of monitors are used: internal and external. An external fetal monitor includes two transducers that are placed on the mother s abdominal wall. One transducer uses ultrasound to detect and record the fetal heart rate. The other transducer, called a tocotransducer, monitors the frequency and duration of uterine contractions and fetal movement. The information from both of these is recorded on a strip chart. The external monitor is non-invasive, so it does not require that the membranes be ruptured or that the cervix be dilated. However, it cannot measure the intensity of the uterine contractions. The position of the laboring patient can affect the readings. The internal monitor includes a spiral electrode and an intrauterine catheter. The cervix must be dilated 2-3 cm, and the membranes must be ruptured to insert these components. Fetal monitor provides a visual tracing for fetal heart tones and uterine contractions. The use of the fetal scalp electrode (FSE) is to better maintain a tracing and requires training to apply. The fetal heart rate (FHR) is graphed at the top, and the uterine activity is graphed at the bottom of the paper. The spiral electrode is attached to the presenting part of the fetus (usually the scalp), and it monitors fetal heart rate. The intrauterine catheter is inserted through the opening cervix into the uterus. It is compressed during contractions and can, as a result, monitor the frequency, duration, and intensity of contractions. It can also measure the resting muscle tone of the uterus. The information is also recorded on a strip chart in the same manner as an external monitor. The nurse assesses the tracing to evaluate the fetal heart rate and uterine contractions. When assessment of the fetal heart rate occurs, assessment of the fetal well being occurs as well. FHT s provide clues that the baby is getting the oxygen it needs or is in distress. Fetal Heart Rate Normal baseline (not during contractions) FHR is 120 to 160 beats per minute. When monitoring the FHR, the nurse is assessing the heart rate and variability. Rate and variability represent the oxygenation of the fetus s central nervous system (CNS). The following are terms to become familiar with when evaluating FHT s. Normal or baseline fetal heart rate beats per minute (BPM) Fetal tachycardia FHR is greater than 160 for more that 10 minutes; common causes include: º Elevated maternal temperature and/or dehydration MODULE 2 INTRAp ARTUM CARE student EDIt IOn 13 CLASSROOM ACTIVITIES Make an appointment to have the students rotate through a simulation lab for OB simulation scenarios to focus on the demonstration of normal and abnormal rhythms of FHR during the stages of labor. Make an appointment to have the students rotate through a simulation lab for OB simulation scenarios to focus on scenarios of normal and abnormal labor progression. Make an appointment to have the students rotate through a simulation lab for OB simulation scenarios to focus on fetal lie using Leopold s maneuver and vaginal assessment. ADDITIONAL CRITICAL THINKING QUESTIONS A patient is in active labor. Her cervix is dilated to 5 cm and her membranes are intact. The FHR and uterine contractions are being monitored by external fetal monitor. The nurse notes a FHR of 115 to 120 beats/min with occasional increases up to 158/min that last 25 sec, and beat-to-beat variability of 20 beats/min. A. There is no slowing of FHR from baseline noted. What signs is the patient exhibiting? Answer: There is a normal FHR baseline of 115 to 120 beats/min. Therefore, there is no evidence of fetal bradycardia or tachycardia. There is moderate variability with FHR accelerations increasing 158 beats/min, lasting for 25 sec. There are no FHR decelerations because the FHR does not slow down. These are all reassuring FHR patterns. B. The nurse auscultates the FHR and determines a rate of 150 to 155 beats/min. What nursing intervention is appropriate? Answer: Normal fetal heart rate is between 110 to 160 beats/min. Therefore, this finding does not need to be reported to the primary care provider. MODULE 2 IntrapARTUM Care TEACHER EDITION 13

16 CLASS DISCUSSION As a class, discuss fetal oxygenation. Answer: A fetus is most oxygenated during the relaxation period of contractions. During contractions, the arteries to the uteroplacental intervillous spaces are compressed resulting in a decrease in fetal circulation and oxygenation. The constriction is most acute during the contraction peak of the uterine contraction intensity, but is also present on the incline and decline of the contractions. ADDITIONAL CRITICAL THINKING QUESTIONS Compare internal to external fetal heart monitoring. Answer: Internal monitoring of the FHR is more accurate than external monitoring. External monitoring can be used throughout the birth process. The membrane must have ruptured and the cervix dilated to at least 2 to 3 cm before an internal º Side effect of some medications º Intrauterine infection Fetal bradycardia FHR less than 120 BPM for 10 minutes; common causes are suspected decreased fetal oxygenation due to the following: º Uterine contractions too close or lasting too long º Maternal drop in blood pressure Accelerations are momentary increases in the FHR baseline. They increase by at least 10 beats above baseline, last for 15 seconds and return to baseline. Accelerations are good signs of fetal oxygenation. Variability fluctuations of the FHR tracing. This is the increase and decrease of beats related to the sympathetic and parasympathetic nervous system. This is one of the best indicators of fetal oxygenation. When moderate variability is noted, that is a good sign of fetal wellbeing. The rating of variability is as follows: º Absent The fetal heart tracing is flat. THIS MUST BE REPORTED TO THE PCP IMMEDIATELY. º Minimal Fetal heart tracing appears to fluctuate only 5 BPM. For example: FHR is between BPM. Minimal variability may be related to pain medication or infant sleep cycle and should be monitored if persistent. º Moderate Fetal heart tracing appears to fluctuate 6-25 BPM. This is considered normal and desirable. The CNS of the baby is well oxygenated and fetal reserve is appropriate. º Marked Fetal heart tracing appears to fluctuate greater than 25 BPM. This may occur with rapid descent of the fetus and should not occur for greater than ten minutes without reporting to the RN or PCP. Decelerations are patterns that can occur within the baseline of the FHR. They may occur with or without contractions and this is important to note. The following are the most common types of deceleration patterns that may occur. Early Decelerations Early decelerations are the result of the fetus head being compressed. The pattern occurs with the contraction and reflects the contraction. The FHT s decrease by several beats and returns to baseline with the end of the contraction. Early decelerations are not a problem. Nursing interventions include: º Notify the RN or PCP of these changes. º Turn the patient to change head compression. º Late decelerations are the result of uteroplacental insufficiency. The pattern occurs with start of a contraction. The baseline drops several beats and does not return to baseline until AFTER the contraction has ended. This means the fetus does NOT have the reserve of oxygen it needs to cope with labor. The fetus is not getting the oxygen it needs to take care of the CNS. THIS MUST BE REPORTED TO THE PCP IMMEDIATELY. º Turn the patient to the side to improve maternal and fetal circulation. º Apply oxygen per face mask at 8-10 liters. º Stop oxytocin drip and notify the RN and PCP. º Monitor hydration status and if maternal hypotension is noted, check standing orders. 14 CIMC MATERNAL NEWBORN NURSING monitor can be placed. Internal monitoring, not external monitoring, increases fetal and maternal risk for infection. A nurse places an external fetal monitor on a patient who is in labor. Which of the following instructions is most appropriate for the nurse to give to the patient? Answer: It is optimal for the patient to lie on her side to increase uteroplacental perfusion and fetal oxygenation. Supine positioning is contraindicated to avoid vena cava syndrome. The patient should be encouraged to reposition herself frequently to promote fetal oxygenation and assist in the progress of labor. Ultrasound transducer and toco transducer will need to be readjusted by the nurse with patient repositioning to maintain a good signal on the monitor. 14 CIMC MATERNAL NEWBORN NURSING

17 Variable Decelerations Variable decelerations are the result of cord compression and may occur with or without a contraction. They drop sharply below baseline and return just as quickly. They appear as a V or W within the baseline. Nursing interventions include: º Change maternal position to see if cord compression improves. º Conduct vaginal exam to check for prolapsed cord. t h E L pn role I n F E t O p ELv IC relationshi p The nurse is also responsible for assessing fetal position and presentation. These may be done by Leopold s maneuvers, vaginal exam and/or ultrasound (US). Some facilities train the nurse to perform a limited US for presentation of the fetus before the patient can be induced. The Leopold s maneuvers require palpation of the abdomen to determine fetal position, number of fetus, and presentation part and require practice to become competent with the skill. This skill is often done by the RN and may not be the responsibility of the LPN. When the fetus enters the pelvis, the preferable entry is with the head. Vertex presentation means that the presenting part is the head. The head can enter in various directions. Face-up is called occipital posterior and face down is called occipital anterior. The preferable direction that presents the least complicated vaginal birth is occipital anterior. There are other types of vertex deliveries, such as face or brow, but will not be discussed in detail. The following presenting parts often require a cesarean section for the safety of the fetus: Breech means the presenting part is the buttocks. Footling breech means the feet or foot is the presenting part. A transverse lie is when the fetus is laying sideways and does not engage into the pelvis. Potential Complications Most deliveries are vaginal and require no special interventions for delivery. When problems arise the nurse must act quickly and be prepared for any emergency. Most labor and delivery units require registered nurses for staffing. However, as a LPN you will need to know what is normal and what complications can occur. learning www links Fundus Examination Video us/play.php?vid=364 Nursing 411 Leopold s Maneuver video org/videos/leopolds_ Maneuvers/Leopolds_ Maneuvers.html MODULE 2 INTRAp ARTUM CARE student EDIt IOn 15 MODULE 2 IntrapARTUM Care TEACHER EDITION 15

18 Complications During Labor Complications Signs and Symptoms Needed Action Post-Term Macrosomia, large fetus Multiple gestation Placenta reaches 40 weeks and begins to slowly calcify and does not work as efficiently The amniotic fluid will decrease and fetus is less protected Fetal reserve is diminished and the fetus does not cope well with labor Places the patient at a greater risk of birthing complications Fetal risk for hypoglycemic reactions FHT s must be monitored carefully Uterus is distended and may have difficulty contracting Present differently, one vertex and the next breech One may be delivered vaginally and the next by emergency CS Non-stress tests to assess fetal wellness Ultrasound Induction of labor is advised before 42 weeks Cesarean section Prepare for complications and fatigue of the mother Hypertonic contractions Too often or do not relax, resulting in fetal distress Discontinue oxytocin Hypotonic contraction Do not promote cervical dilation Delayed delivery with the possible complication of infection or fetal distress Increased risk that after delivery the uterus becomes boggy and places the patient at risk for post partum hemorrhage Inhalation of amyl nitrate to relax the uterus or SQ terbutaline (usually done by an RN) Possible interventions include: Artificial rupture of membranes (AROM), augmentation with oxytocin 16 CIMC MATERNAL NEWBORN NURSING 16 CIMC MATERNAL NEWBORN NURSING

19 Complications During Labor Complications Signs and Symptoms Needed Action Uterine rupture Abruptio placenta Occur with a prolonged, obstructed labor Ruptures while the fetus is still inside, resulting in hemorrhage of patient and fetus Placenta detaches too early from the uterine wall, before or during labor, and blood and oxygen are cut off to the fetus Visible bleeding can occur if the detachment is low Great deal of pain Bleeding can be hidden by the pressure of the fetal head Assess patients in labor for sharp abdominal pain during contractions, abdominal tenderness, signs of shock, loss of FHR, and vaginal bleeding VERY SERIOUS EMERGENCY THAT REQUIRES QUICK RECOGNITION AND TREATMENT Immediate surgery will be required to deliver the infant and repair the uterus, if possible A hysterectomy may be necessary Monitor FHT s and UC s. Very serious emergency that requires quick recognition and treatment Prepare for emergency CS if abruption is large and FHT s are non-reassuring Placenta previa complete or partial Complete placenta previa occurs when the placenta implants over the cervical inner os Placental abruption Monitor FHT s and contractions Prepare for emergency CS for hemorrhage, abruption, or abnormal FHTs Free Complication Sample because, as the Provided by CIMC pregnancy advances, the cervix thins and opens Separation of the placenta at the cervix and painless vaginal bleeding MODULE 2 INTRAp ARTUM CARE student EDIt IOn 17 MODULE 2 IntrapARTUM Care TEACHER EDITION 17

20 ADDITIONAL CRITICAL THINKING QUESTIONS Compare the use of the following medication: calcium gluconate, oxytocin, magnesium sulfate and prostaglandin. Answer: Magnesium sulfate is an anticonvulsant that would be prescribed for a patient exhibiting signs and symptoms of sever preeclampsia with the symptoms of elevated blood pressure and 3+ proteinuria. Oxytocin is used to augment labor. Calcium gluconate is the antidote for magnesium sulfate and used in the event of magnesium sulfate toxicity. Prostaglandin is administered into the amniotic sac or by a vaginal suppository to augment or induce labor. Hypertension in pregnancy The mother and fetus are negatively affected when the patient has high blood pressure. If hypertension occurs with pregnancy and disappears with delivery, the diagnosis is usually pregnancy induced hypertension (PIH). Hypertension can result in a smaller fetus and placenta, with an increased risk for other complications such as abruption and preterm delivery. Blood pressure problems can exist before pregnancy and are referred to as chronic hypertension. Pre-eclampsia is hypertension with the addition of protein in the urine called proteinuria. Pre-eclampsia is a complication that can lead to maternal seizures and becomes eclampsia. During the seizure the infant is exposed to danger due to the lack of oxygen. Persons with severe pre-eclampsia may develop HELLP syndrome: H = Hemolysis EL = Elevated liver enzymes LP = Low platelet count. Laboratory tests are performed to diagnose severe pre-eclampsia. Intrauterine fetal death (IUFD) This can occur anytime after 20 weeks gestation. If it occurs before 20 weeks gestation, then it is called a miscarriage. There are many reasons that an IUFD can occur, such as a cord accident or a placental abruption. Many times a reason is not found. The psychological support of the patient is important. Reassure the family that you are there for them and will answer any questions. Many hospitals have programs to help families deal with an IUFD. Cephalopelvic disproportion Cephalopelvic disproportion occurs when the fetus s head is too large to pass through the mother s pelvic inlet and outlet. Pelvic measurements help the physician determine the likelihood that cephalopelvic disproportion may occur. However, this complication may not be identified for certain until labor has begun but does not progress. A cesarean delivery will be done if the fetal head cannot pass through the mother s pelvis. Occiput posterior presentation When the baby s head is positioned so that the face will be up at delivery, it is said to be occiput posterior (OP). Because of this position, the labor may not progress well. The mother experiences increased pain, especially back pain. The nurse can help relieve some of the discomfort by assisting the patient with pelvic rocking and by applying counter pressure to the patient s lower back. This helps lift the infant s head off of the mother s spinal cord. The nurse also needs to give the patient emotional support. A cesarean delivery may be required. Precipitous delivery Sometimes a birth occurs so quickly that the usual preparations cannot be made. The PCP may not even be present. This is more likely to occur in a multipara than a primipara. The nurse may be the only person available to assist in a precipitous delivery. If this occurs, the nurse should: Never leave the patient alone. Call for help using the call light or intercom. If at all possible, wash, put on gloves, and place a sterile drape under the patient. Remain calm and reassuring to the mother. Never forcibly hold the infant s head back to delay the birth it can cause fetal distress. Prolapsed cord The umbilical cord can prolapse (protrude into the vagina) before or beside the presenting part of the fetus. This can be caused if the membranes rupture before the presenting part is engaged in the pelvis or if the presenting part is a shoulder or foot. A premature birth, because the fetus is small, allows more room for the cord to prolapse. A prolapsed cord may also be seen with placenta previa. 18 CIMC MATERNAL NEWBORN NURSING Contrast missed abortion, ectopic pregnancy, severe preeclampsia and hydatidiform mole. Answer: Signs and symptoms of an ectopic pregnancy include unilateral lower quadrant abdominal pain with or without bleeding. A missed abortion occurs when products of conception are retained and there is a brownish discharge. Severe preeclampsia does not have vaginal bleeding unless initiated by worsening complications and presents with an epigastric, right upper quadrant pain. Hydatidiform mole causes dark brown bleeding in the second trimester and is not generally accompanied by abdominal pain. 18 CIMC MATERNAL NEWBORN NURSING

21 If the nurse can see the cord or palpate it in the vagina or cervix, a prolapsed cord is occurring. If the cord is compressed against the mother s pelvis and the fetus, oxygenation to the fetus will be decreased or obstructed. The FHR may be irregular with periodic bradycardia. The nurse should place the mother in Trendelenburg position and administer oxygen by mask. The PCP should be notified immediately. Uterine dystocia Problems with the uterus that can contribute to a difficult labor include abnormally-shaped uterus, scar tissue in the uterus, fibroid tumors of the uterus, and over-distention of the uterus due to multiple pregnancy. Contractions of the uterus can either be hypertonic or hypotonic, causing uterine dystocia. Hypertonic contractions occur when the contractions are uncoordinated and involve only portions of the uterus. They are very strong contractions but ineffective for causing effacement and dilation of the cervix. D ELIv E ry COMp LICatIOns Sometimes an infant cannot be delivered without assistance or cannot be delivered vaginally. Forceps are spoon-shaped tong-like instruments used to help deliver the fetal head. Several different types exist. They are often used to deliver the aftercoming head in a breech presentation. Cesarean delivery is done by making an abdominal incision and an incision through the uterine wall through which the infant is born. It is performed in approximately 20 percent of deliveries. Reasons for cesarean deliveries include: Cephalopelvic disproportion Breech presentation Fetal distress Placenta previa Abruption Vaginal infections such as herpes genitalis Hypotonic contractions are not as intense as needed to bring about effacement and dilation. This may be because the fetal head cannot fit through the pelvis or because the uterine tone is flaccid. Oxytocin may be ordered to increase the intensity of the contractions. MODULE 2 INTRAp ARTUM CARE student EDIt IOn 19 MODULE 2 IntrapARTUM Care TEACHER EDITION 19

22 ADDITIONAL CRITICAL THINKING QUESTIONS A patient is sleeping well and wakes up two hours later. Her contractions are every three to five min. and stronger. Her cervix is 3cm dilated, 80% effaced, and -1 station. The patient states that she wants pain medication at this time. A. What are some interventions the nurse can suggest at this time? Answer: Patterned breathing techniques; frequent emptying of the bladder; Stadol 2 mg IV prescribed; application of heat or cold; distraction or a focal point. Nonpharmacologic comfort measures can be safely used at this time while the patient is in the latent phase of labor. The patient may have the opioid analgesic. B. The patient is 5cm dilated and displays restlessness, moaning, and is beginning to hyperventilate. She says the breathing and other techniques aren t working, and asks the nurse to give her something for pain. The nurse obtains a prescription for Stadol 2mg IV. What are the nursing implications for this medication? L E a r n I n g O b j E C t I v E s Objective Objective Identify types of pain management used during labor. Describe the physiological and psychological care for a patient during labor and delivery. p hysiolog ICa L and p syc h OLOg ICa L nursi n g CarE Pain Management The nurse supports the patient throughout the labor process. Very few births occur without pain. Pain management interventions may include relaxation exercises, massage, a warm shower, walking, and/or sitting on a labor ball. These work well for some, but not for all. Encouragement and letting the patient know they are not alone and that she can do this is one of the most important interventions for a delivery without medications. Many times patients will arrive with a birth plan that states she does not wish to use medications. Occasionally the patient will change her mind during labor and ask for the pain relief medications. It is important to remain supportive and nonjudgmental. Every patient experiences pain differently and must not feel that they have failed because they used pain medications. Encourage and explain that it is not a weakness and is okay to use medications if she needs them. It is important to remember that when a patient has a birthing plan that requests no medications, the patient should be the person who brings up pain medications. Often the patient will ask you what you think. It is important to explain the use of medications in a non-partial manner and tell the patient it is up to her. Remaining neutral helps the patient feel in control and supported. Because labor can be long and intense, many women need analgesia and/or anesthetic during this time. The physician must determine what type of medications should be given and when, in order to prevent the fetus from being adversely affected. These medications can cross the placental barrier and depress the respirations of the infant at birth. Patient teaching regarding the complications of these medications may be needed. It s important for the healthcare team to use caution in the administration and timing of medications in relationship to the events of labor. Narcotic analgesics, such as meperidine (Demerol) and butorphanol tartrate (Stadol), are ordered IM or IV. Antianxiety agents, such as hydroxyzine HCL (Vistaril) or diazepam (Valium), may be ordered to reduce anxiety and as an adjunct to the narcotic medications. Regional anesthetics include paracervical, epidural, spinal, and pudendal blocks. A paracervical block is an anesthetic administered on either side of the cervix as it dilates, causing lack of feeling in the cervix and uterus. It can slow labor. An epidural block is an anesthetic administered into the epidural space at the end of the spinal canal. A catheter may be inserted and left in place during labor, so that the anesthesia can be administered periodically. An epidural block causes anesthesia of the pelvic region. It can cause maternal hypotension and may slow labor if started too early. It will also prevent the mother from being able to push in the second stage of labor if it is still present, and may cause fetal heart decelerations. Nursing Interventions Confirm there is a consent signed, assist the PCP in preparing the patient for an epidural, administer an IV fluid bolus, and monitor the mother and fetus before and after the epidural. Epidural checks are required every 30 minutes after insertion. The level of the epidural is tested by the nurse to insure the level does not go too high and does not decrease or stop respirations. A spinal block is given into the epidural space around the spinal cord. It causes anesthesia from the point it is administered downward. It may be given to anesthetize from the waist down for a cesarean section. It can cause hypotension and post-spinal headache. 20 CIMC MATERNAL NEWBORN NURSING Answer: The nurse monitors the patient for signs of allergic or adverse reactions; the nurse has naloxone available to administer for respiratory depression of the neonate; the nurse has an emesis basin available in the event of nausea and vomiting. C. The patient is 8cm dilated, 100% effaced, the fetus is at -1 station, and the membranes have ruptured. She states the pain is worse than ever and wants more of the IV pain medication, Stadol, which she received 3 hours earlier. What is the best nursing action? Answer: Notify the primary care provider and obtain a prescription for epidural anesthesia if the patient is requesting pharmacologic pain relief. It is too close to delivery for IV opioid administration. It is possible that the patient might deliver while the opioid is at its peak level causing respiratory depression in the neonate. It does not make a difference how frequently the Stadol is prescribed to be given if it is too near delivery time to administer an opioid. 20 CIMC MATERNAL NEWBORN NURSING

23 A pudendal block is injected into the pudendal nerves and causes anesthesia of the perineum. It has no side effects unless there is an allergic reaction to the anesthesia used. Different people and different cultures react differently to pain, and the pain of labor and delivery is no exception. Laboring mothers or their partners may feel that the women are not receiving enough medication to manage their pain. It is important to reassure the patient and her partner and to explain that possible effects on the baby influence the physician s decisions about the type, amount, and timing of analgesia/anesthesia administration. Physiological and Psychological Care for a Patient Patients may be fearful of the pain and process of labor, and are often fearful about the health and well-being of their baby. It is very important for the nursing staff to be reassuring and calming during all the stages of labor. Some cultures value the characteristic of stoicism during labor. Other cultures expect the mother to be very vocal during labor. Many cultures do not believe that the father should be with the woman during labor and delivery. Older women assume that role. It is very important for nurses to support the patient and her partner in taking roles that are comfortable for them. It is not up to the nursing staff to insist that the father or partner be present during the first and second stages of labor. L E a r n I n g O b j E C t I v E Objective Discuss responsibility of the LPN/ LVN while caring for the mother and newborn during labor and delivery. M O the r and newbo rn CarE During a vaginal delivery, immediately after the infant is delivered, the nose and mouth are suctioned with a bulb syringe to clear the airway. The infant usually begins breathing and crying once delivery is complete. If stimulation is needed, the physician rubs the soles of the infant s feet. The umbilical cord is clamped with a special clamp about two inches from the infant s abdomen and again several inches above. The cord is cut between the two clamps. The cord is inspected for the presence of two veins and an artery. Any abnormalities are noted and documented. Apgar scores are determined. The Apgar is an assessment of the infant s heart rate, respirations, muscle tone, color, and response to stimulation. The assessment is done one minute after birth and again five minutes after birth. A score of 8 to 10 is desirable, with 10 being the highest possible score. Generally the Apgar score increases by approximately 1 to 2 points at the five-minute assessment. The infant is shown to the parents, unless an emergency situation requires intervention. The mother may hold the infant, or it may be placed in a warmer. It is important to keep the baby warm and dry to prevent heat loss. The infant is assessed frequently and, if any problems occur, the parents should be reassured and supported. Matching identification bracelets are placed on the mother and the baby. The third stage of labor is the delivery of the placenta. It lasts from 5 to 20 minutes. The placenta naturally detaches from the uterine wall as the uterus shortens. A sudden gush of blood from the vagina indicates that the placenta is about to be delivered. The patient feels a few contractions and pushes one or two times to deliver the placenta. The appearance of the placenta is noted and documented. MODULE 2 INTRAp ARTUM CARE student EDIt IOn 21 ADDITIONAL CRITICAL THINKING QUESTION A patient is in the fourth stage of labor, has just delivered a newborn, and is stable. The nurse knows that during the maternal recovery period vital signs should be assessed at regular intervals. What are the appropriate vital sign intervals? Answer: The fourth stage of labor is referred to as the maternal recovery period which lasts from one to four hours. If all factors are stable, postpartum assessments of vital signs as well as uterine firmness, location, and position should be done every 15 minutes for the first hour, every 30 minutes for the second hour, hourly for at least two hours, and then every four to eight hours for the remainder of the patient s hospitalization. learning www links Newborn Delivery Medication and Treatment com/article/ treatment Childbirth Video Gallery givingbirthnaturally.com/ childbirth-video.html Childbirth Video Clips Medical Videos Full Obstetric Examination & Normal Delivery us/videos-1253-full- Obstetric-Examination CLASSROOM ACTIVITY Make an appointment to have the students rotate through a simulation lab for OB simulation scenarios to focus on the simulation of fourth stage of labor for the mother and neonate recovery scenarios. MODULE 2 IntrapARTUM Care TEACHER EDITION 21

24 learning www links Medical Videos Videos of different types of births us/videos-1294-natural- Vaginal-Child-Birth- Delivery-Video us/videos-2459-vaginal- ChildBirth-after-Cesarean- Section-C-Section The fourth stage of labor is stabilization of the mother. After delivery of the infant and placenta, the uterus contracts to smaller and smaller size. As it contracts, the muscle fiber network causes compression on the blood vessels that were attached to the placenta, controlling bleeding. The nurse assesses the mother s vital signs, the size and location of the uterus, firmness of the uterus, the amount and type of vaginal drainage, and the appearance of the episiotomy and other tissues. If the uterus is soft, the nurse will massage the fundus to control bleeding. The nurse also assesses the amount of vaginal bleeding by counting the number of pads saturated per hour. Nursing Interventions For the first hour after delivery, the nurse monitors the following every 15 minutes: Newborn color and respiratory effort. Maternal vital signs monitor for unexpected values. Uterine position expected to be midline and at the umbilicus. Uterine tone expected to be firm and is massaged to promote firm tone. Lochia flow expected to be small to scant. º Massage first and if bleeding continues, notify the RN and/or PCP. º Monitor for clots or heavy flow. Note: Heavy flow and clots can mean retained placenta and can lead to dilation and curettage (D&C). In extreme hemorrhages the patient is at risk for a hysterectomy (removal of the uterus). Episiotomy if present, edges are approximated. Bladder empty or distended. Remember that there is a lot going on hemodynamically during this time and fluid shifts cause diuresis. If the bladder becomes over distended, the uterus can become boggy and increase lochia flow. If all of the above are within normal limits, after one hour the assessment occurs every 30 minutes for an hour. us/videos-2289-caesareansection-for-a-breech us/videos-2433-vacuum- Extraction us/videos-2172-midline- Episiotomy us/videos-237-episiotomy- Repair us/videos-2499-amniotomy IMPORTANT FACT: After delivery, breast feeding patients are encouraged to breast feed as soon as possible to help the infant to latch on. Latch on is when the infant has the nipple and areola properly positioned in the Free Sample mouth. When the infant Provided is properly latched by CIMC on, the mother s breasts are less sore. us/videos-328-forceps-in- Childbirth 22 CIMC MATERNAL NEWBORN NURSING 22 CIMC MATERNAL NEWBORN NURSING

25 L E arni ng act I v I ty 2 n a ME Introduction Providing psychological support is important during labor and delivery. a ctivity Consider each of the following situations. Decide how the nursing staff can best provide emotional support to each of these women. s ituation a Mary Mandelay is a 22-year-old primipara. She seems very frightened when the nurses come into the room. Her partner, Juan, a 23-year-old male, seems very uncomfortable. He paces the room and changes the television stations constantly. Mary is very quiet initially but, as labor progresses, she begins to cry and scream with each contraction, while still in the early phase of the first stage of labor. Her partner often walks out into the hall and asks the nurses to give her something to calm her down. No other family members are present. What can the nursing staff do to provide emotional support to Mary? What can the nursing staff do to provide emotional support to Juan? s ituation b Tamara Henderson is a 34-year-old multipara. She is a gravid 3/para 2. She states that she is worried about whether the baby will be all right. She had taken some prescription medications early in her pregnancy before she was aware that she was pregnant, and she is concerned that the baby will have some kind of defect. She has had an amniocentesis and other tests that did not indicate any problems. Her husband is with her. He tells her, Now, Tamara, everything is going to be fine. Quit worrying so much. She does not seem reassured by his words. As the labor progresses, she begins to cry. She tells the nurse she does not need further pain medicine, but that she is afraid of what the baby will be like. What can the nursing staff do to provide emotional support to Tamara? Does her husband need emotional support at this time? If so, what should the nursing staff do? MODULE 2 INTRAp ARTUM CARE student EDIt IOn 23 Situation B The nursing staff can provide emotional support to Tamara by allowing her to discuss her fears and reassuring her that no problems were detected in the tests. They should do this without belittling Tamara s feelings and fears. The nursing staff can also encourage her to focus on the healthy delivery of her baby. Tamara s husband may need emotional support as well. He may not realize that he is not reassuring her with what he says. The nursing staff can help involve him in the labor as coach and supporter, helping both of them focus on the healthy delivery of the baby. LEARNING ACTIVITY ANSWERS Situation A The nursing staff can provide emotional support to Mary by telling her what to expect as labor progresses. Nursing staff can also help coach her through breathing techniques and use distraction during the early stages of labor. Nursing staff can ask if Mary wants any other support people to be called to be with her during labor. Praise her for all that she accomplishes. The nursing staff can provide emotional support to Juan by explaining what he can do to help Mary. They can teach him how to coach Mary with breathing techniques and how to help distract her during early labor. They can also ask if he wants any other support people to be nearby during labor. They can kindly explain when and why medication can and cannot be given during labor. MODULE 2 IntrapARTUM Care TEACHER EDITION 23

26 Situation C The nurse can offer emotional support to Cynthia by helping manage her pain and by helping her understand what is happening as her labor intensifies. The nurse can gently soothe and coach Cynthia into using the breathing techniques she has learned. The nurse can allow Cynthia to verbalize her distress and understand that the labor is more intense than she had anticipated. s ituation C Cynthia Salenski is a 30-year-old primipara. She has been in labor for six hours and has entered the mid or active phase of labor. Her husband and her mother are at her bedside. She and her husband took Lamaze classes and he is her coach. As she progresses in the active phase of labor, she becomes increasingly irritable. She yells at her husband as he tries to coach her through the contractions using breathing techniques. He leaves the room in frustration. Her mother attempts to soothe her, but Cynthia tells her mother to get out and leave her alone. Her husband tells the nurse that Cynthia is usually in control, always cool and calm. As he says this, the nurse and he can hear Cynthia cursing him during a contraction. How can the nurse offer emotional support to Cynthia? How can the nurse offer emotional support to her husband and her mother? a pplication Use these scenarios and responses to compare with other situations that you have heard regarding the birthing experience. Be prepared to handle similar situations in the clinical environment. The nurse can give emotional support to Cynthia s mother and husband by explaining that the labor has intensified beyond what Cynthia was prepared to endure. The nurse can explain what is being done to help relieve some of Cynthia s pain. The nurse can suggest ways for the husband and mother to be helpful without necessarily talking to her during contractions. They can rub her back, keep a cool cloth on her forehead, and just quietly be with her. 24 CIMC MATERNAL NEWBORN NURSING 24 CIMC MATERNAL NEWBORN NURSING

27 KEy s UMMary ɶ The birth process requires careful monitoring of the patient and fetus. ɶ Physiological and psychological care is balanced between safety and the patient s expectations. ɶ True labor requires cervical change. ɶ Braxton-Hicks contractions occur with false labor. ɶ Induction of labor is ordered when the fetus is better off outside the womb due to factors such as fetal size and expected delivery date. ɶ Augmentation is increasing uterine contraction intensity and frequency to cause cervical change. ɶ Induction and augmentation can be achieved through artifical rupture of membrane and/or oxytocin drip. ɶ The first stage of labor begins with mild contractions and is divided into three phases: latent, active and transition. This stage begins with the onset of cervix dilation 0-2 cm and ends when the cervix is completely dilated. ɶ The second stage of labor starts with complete dilation of the cervix, 10 cm, and ends with the delivery of the baby. ɶ The third stage of labor begins with the delivery of the baby and ends with the delivery of the placenta. ɶ The fourth stage begins after the delivery of the placenta and ends after four hours. ɶ Evaluation of fetal oxygenation is assessed through accurate assessment of FHT s. ɶ Patients have the right to choose the pain management right for them and to change their mind if needed. ɶ Pain can be managed with breathing and relaxation techniques and/or various analgesics and analgesia. MODULE 2 INTRAp ARTUM CARE student EDIt IOn 25 MODULE 2 IntrapARTUM Care TEACHER EDITION 25

28 ɶ The RN can do vaginal exams to check cervical dilation and station of the fetus. However, this exam is not within the scope of practice for the LPN. ɶ Contractions start out mild and progress to moderate then strong in intensity. Uterine contractions are measured by duration, frequency and intensity. Duration is how long a contraction lasts. Effective contractions are from seconds and a rest period, or relaxation, of 1-3 minutes is required to supply oxygenated blood to the fetus. ɶ The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. ɶ Even with the best planning, emergencies and complications can occur in L&D and the nurse must be prepared. ɶ Post-delivery assessments must be completed every 15 minutes for the first hour. 26 CIMC MATERNAL NEWBORN NURSING 26 CIMC MATERNAL NEWBORN NURSING

29 g LOssary Amniotomy: Artificial rupture of membranes used to induce or augment labor. Augmentation: Done when the uterine contractions have decreased and/or labor has stalled or not progressed. Medications such as oxytocin or an amniotomy may be used to augment labor. Braxton-Hicks contractions: Often called false labor and are usually mild and mistaken for true labor. Caput: The head of an organ. Dilation: The opening of the cervix for birth. Measured in centimeters. Effacement: The thinning of the cervix. Measured in percentages. Episiotomy: Surgical cutting of the perineum to enlarge the vaginal opening. False labor: Contractions that are usually irregular and do not cause dilation of the cervix. Fundus: The top of the uterus that is measured, palpated and massaged during pregnancy. GTPAL: Gravida (G) = total number of pregnancies, Term (T) = number of pregnancies carried to 37 weeks, Preterm (P) = number of pregnancies delivered before 37 weeks, Abortions (A) = number of elective or spontaneous abortions, Living (L) = number of living children at this time. Hyperstimulation: The uterus is having contractions that are too often or do not rest and will cause fetal distress. Intrapartum: The phase of pregnancy when delivery takes place. Lochia: The bloody postpartum vaginal discharge. Macrosomia: The fetus is estimated large, about 9 pounds. Meconium: First stool of the newborn. Meconium stained fluid is stool passed in utero and may cause complications if thick and inhaled at birth by the newborn. Mucous plug: A thick yellowish piece of mucous that is located in the cervical os and prevents the ascent of bacteria into the uterus. MODULE 2 INTRAp ARTUM CARE student EDIt IOn 27 MODULE 2 IntrapARTUM Care TEACHER EDITION 27

30 Multipara: More than one birth and not the first birth. Gynecoid pelvis: Most common shape of pelvis and ideal for vaginal birth. Pre-eclampsia: A disease of pregnancy with symptoms of hypertension, proteinuria, edema, hyperreflexia and visual disturbances. Primipara: The first birth. Spontaneous rupture of membranes (SROM): Spontaneous rupture of the amniotic membrane, often referred to as water breaking. True labor: Uterine contractions that start out mild and irregular, then increase in intensity, regularity, duration and frequency, resulting in dilation of the cervix. 28 CIMC MATERNAL NEWBORN NURSING 28 CIMC MATERNAL NEWBORN NURSING

31 res OUr CE bib LIOgraphy Christiansen, B. L. & Kockrow, E. O. (2006) Foundations & Adult Health Nursing. St.Louis, MO: Mosby. Leifer, G. (2007). Introduction to Maternity & Pediatric Nursing. St.Louis, MO: Mosby. Leifer, G. (2006). Maternity Nursing, An Introductory Text. St. Louis, MO: Mosby. London, M.L. Ladewig, P.W. Ball, J. W. and Bindler, R.C. (2007) Maternal & Child Nursing. New Jersey: Prentice Hall. Nursing Focus: Labor and Delivery Focus. Stillwater, OK: Oklahoma Department of Career and Technology Education, Curriculum and Instructional Materials Center, Nursing Focus: Postpartum Focus. Stillwater, OK: Oklahoma Department of Career and Technology Education, Curriculum and Instructional Materials Center, Nursing Focus: Infant Focus. Stillwater, OK: Oklahoma Department of Career and Technology Education, Curriculum and Instructional Materials Center, Ramont, R. P. & Niedringhaus, D.M. (2008) Fundamental Nursing Care. 2nd Ed. New Jersey: Prentice Hall. Timby, B.K. (2009) Fundamental Nursing Skills and Concepts. 9th Ed. Wolters Kluwer/Lippincott Williams &Wilkins. MODULE 2 INTRAp ARTUM CARE student EDIt IOn 29 MODULE 2 IntrapARTUM Care TEACHER EDITION 29

32 not E s 30 CIMC MATERNAL NEWBORN NURSING 30 CIMC MATERNAL NEWBORN NURSING

33 ADDITIONAL Learning Activity Name Introduction This activity allows you to familiarize yourself with medications commonly used in L&D. Activity Look up the following medications in a drug book. What are the nursing implications related to L&D for administering the med? Butorphanol tartrate - (Stadol) Nalbuphine hydrochloride - (Nubain) Meperidine - (Demerol) Morphine Oxytocin Terbutaline Application List what each medication is used for and when it is contraindicated to use the medication. MODULE 2 IntrapARTUM Care TEACHER EDITION 31

34 ADDITIONAL Learning Activity Answers Name Drug Indications Contraindications Butorphanol tartrate (Stadol) Nalbuphine hydrochloride (Nubain) Narcotic used for pain relief in the early stages of labor Can be given IV or nasal spray Opiate agonist-antagonist comparable to morphine Advantages are it begins working within 5 minutes and has minimal nausea and fetal effects Can cause respiratory depression in the infant Can cause central nervous system depression in infant and mother Meperidine (Demerol) Oxytocin Alters how pain is recognized, starts working in less than five minutes and can be administered into muscle, vein or by PCA pump If given within 2 to 4 hours before delivery Can cause breathing difficulties for infant Natural hormone that causes uterus Do not use if patient: to contract for induction of labor, strengthening labor contractions and controlling bleeding after childbirth Had prior delivery by C-section Is not in controlled clinical setting where uterine contractions can be monitored Terbutaline Derived from the hormone epinephrine and used to treat preterm labor Reduces the number and length of contractions Is having premature labor Has placenta previa or breech birth Women with heart disease, hyperthyroidism, and poorly controlled diabetes should not take terbutaline 32 CIMC MATERNAL NEWBORN NURSING