Michelle L.

Murray, PhD, RNC-OB Family Nursing 2580 Spring, 2012

By the end of this semester you should be able to:

 Identify the 2 phases and 4 stages of labor.  Create a plan of care for an uncomplicated labor.  Discuss the collaborative role of the nurse when there is a complicated labor.  Identify FHR patterns that are reassuring or Category 1 or nonreassuring or Category 2 or 3.  List 5 things the nurse can do when there is a Category 2 or 3 FHR pattern.  Refer to the syllabus for learning content.  Keryotype-chromosome found with amniosythesis

After reading the chapter and by the end of this seminar you should be able to: 1. List 2 signs of impending labor. 2. Differentiate 3 signs of true vs. false labor. 3. Understand the role of prostaglandins and oxytocin. 4. List 3 signs of preterm labor (PTL). 5. Discuss problems of the 3 Ps: Psyche, Passenger, and Powers.
6.

Describe the nurses role when a patient has PTL or there are decelerations in the FHR.

Signs of Impending Labor False Labor and True Labor Physiology of Labor Preterm Labor The 4 Ps of Labor: Psyche, Passenger, Passageway and Powers  Dystocia  Fetal Heart Rate Monitoring: Overview     

May experience 1 or more:  Braxton-Hicks contractions (increase)  Backache (Relaxin: peptide hormone breaks down collagen-widens pubic bone)  Lightening: fetus descends (pelvic inlet)  Cervical ripening (softening; Relaxin)  Bloody Show: mucus plug plus streaks of blood  GI symptoms (possible): D/N/V/indigestion  Energy spurt (possible): 24-48 hours prior to birth  ROM: 12% rupture before labor, 80% will go into
spontaneous labor after, if not, expect labor within 12-24 hours and induction

False labor
 Contractions irregular  Walking MAY relieve contractions

True labor
 UCs gradually develop a pattern and intensify over time  Myth: UCs are more effective with walking  Discomfort in lower back/abdomen  Bloody show often present  Progressive dilation and effacement of the cervix

 Bloody show usually not present  No change in dilatation or effacement of cervix

 Hormonal changes: Progesterone decreases  Prostaglandins are produced  Oxytocin receptors increase  Oxytocin is released  Fetal hormone (oxytocin) production  Uterine distention (myth)

Stages 2 or 3 Phases 1st Stage 2nd Stage 3rd Stage 4th Stage 1st Stage: Latent Phase, Active Phase or Latent Phase, Active Phase, Deceleration Phase

 Not hormones but mediators  Derived from fatty acid (arachidonic acid) that has been acted on by cyclooxygenase (COX-2)  AA + COX-2 PGF2 or PGE2  Cytokines can trigger production of PGs  Increase calcium in the uterine cells  Calcium is a messenger of force

Oxytocin bound to Oxytocin Receptors Triggers the production of prostaglandins PLUS Increases the amount of calcium in the uterine muscle cells.

   

Labor that starts after the 20th week but before the end of the 37th week Etiology not always fully understood 1/3-placental factors, 1/3-infection, 1/3-other Other:
      

Maternal medical conditions (such as appendicitis) Use of reproductive technologies/Preeclampsia Genetics Social (stress, trauma) Environmental factors (like what?) Drugs (especially cocaine) Demographics (such as?)

Signs and Symptoms

       

Often subtle Intermittent cramps, may or may not be aware or interpret as painful Low backache; constant, or intermittent, irregular Pelvic pressure; pressure in vulva or thighs Abdominal cramps; may have diarrhea Change or  in vaginal discharge Cervical changes


Cervical effacement of 80% or > or dilatation of > 1 cm

Just not feeling good

Issues: Physical Emotional Financial Ethical  In-hospital care  Viability/Gestational Age  Duration of Care  DNR

Community education
 

Factors that  risk Consequences of preterm birth Importance and access ID at risk population Nutrition Educate: signs and symptoms Women and significant other: role in seeking care

Prenatal care
    

Diagnosis of Preterm Labor

  

  

Physician diagnosis (not RN diagnosis) Call the physician and ask them to come to the bedside Nurses role: physical assessment, may draw blood and/or submit order for lab studies Set up for SSE (sterile speculum exam) Bring portable Ultrasound to bedside Provide Fetal fibronectin (fFN) swab The glue that holds the placenta down. A sticky glycoprotein present on the back of the placenta Fibronectin receptors in the decidua Results: Negative ~ 22-37 wks; if positive,  risk preterm birth within 2 weeks

 Physician may assess length of cervix (if vaginal ultrasound should be 3 cm +/-)  If less than 25 mm 2.5 cm): vaginal microorganisms have a shorter distance to access the uterus  Infection/endotoxins may weaken membranes, resulting in PPROM (preterm premature rupture of p the membranes)  RN Role: Assess for signs and symptoms of infection and rupture

Nitrazine  Fern test: A positive test shows the presence of fern-like patterns characteristic of amniotic fluid crystals. Supplies:  Sterile speculum exam (SSE)and sterile swab


Access fluid in posterior fornix (if any)  Avoid collecting mucus (mucus plug)


 

Clean glass slide Microscope

Can Preterm Labor Be Stopped?  Terbutaline (Brethine): Now FDA warning  Antibiotics (of no use once cytokines are released)  Restrict activity if PPROM

 Hydration: if dehydrated to release of AVP (arginine vasopressin/antidiuretic hormone)

Tocolytics (Beta sympathomimetics/adrenergics)

(Ritodrine NOT AVAILABLE & Terbutaline FDA WARNING)  Side effects   HR (often hold if pulse > 120, or per protocol)  Hold and discuss with MD/DO if HTN or hyperthyroidism or Diabetic  Assess V/S, FHR and UA before and after  Breath sounds: shortness of breath, c/o palpitations (most common)  Metabolic changes: check blood glucose levels  Restlessness, tremors, nervousness  Usual dose: 0.25 mg SQ (or IVP-dilute first)

Magnesium Sulfate (IVPB on a pump/buretrol or volutrol: High-alert medication)  Calcium channel blocker  Decrease calcium -  uterine contractions  Off-label use  Excreted in urine (strict I and O)  Assess deep tendon reflexes (DTRs), respiratory status, usually OK urinary output (not preeclamptic)  Criteria to continue: UO 30 mL/hr, presence of DTRs, min 12 resp/min  Mg levels?  Reflexes, respirations, urine output q 1 hour

Tocolytics
 Calcium channel blockers
 Nifedipine (Procardia)  Assess BP closely  Do NOT give close to MgSO4 discontinuation

 Prostaglandin Synthesis Inhibitors (COX-2 inhibitors)

 Indomethacin  Toradol (NSAID)  Do NOT give after 32 weeks of gestation

Betamethasone (Celestone)  Corticosteroid  12 mg IM 24 hours apart  23-34 weeks of gestation  To stimulate surfactant development  For lung maturity  45-50% decrease in respiratory distress

Photo from Wikipedia: en.Wikipedia.org/ Wiki/Preterm_birth

 Psyche  Passageway

 Passenger

 Powers

From: www.vision.ee.ethz.ch

Factors influencing response  Labor experience: sense of control?  Childbirth preparation  Expectations (Birth Plan?)
      Identify stressors Assess coping & support Be nonjudgmental Support & show respect Express confidence Praise efforts

ANXIETY Increased Pain  Serum epinephrine

Norepinephrine increases number of contractions  analgesia/anesthesia  Uterine contractility  Length of labor

 Apgar

Unprepared Response

Signal Contraction

Prepared Response

Anxiety, tension Inability to cope; fragmented, disorganized responses

Concentration, directed motor activity Continued coping behavior

 muscular, visceral response

Cognitive responses

Self-image of being unable to cope

Self-image being able to cope

Nursing to  anxiety
 Explore past experiences or family member experiences  Identify cultural needs  Educate about the process and plan of care  Provide supportive careis there a doula?  Provide personal space  Consider alteration in body image (privacy)  Help maintain control
 Assess focus of attention, keep informed, allow choices,  Support childbirth prep techniques, reassure  Be a patient advocate

 Orthodox Jewish patients prefer to bring their own food. Nurses can assist by facilitating refrigerator space in the patients room, or on the unit.  One additional issue nurses may encounter is the completion of birth certificates. Parents will not name their son until the babys eighth day of life when he is ritually circumcised (brit milah or bris).  Girls are usually named in the synagogue by their father on the first Sabbath, or on a day during the week when the Torah is read.  It may require some flexibility and understanding of this tradition and holding paperwork for parents to return after these ceremonies have been completed.

 Establish rapport:
 Welcome family, determine family expectations, convey confidence, respect culture  Provide timely interventions  Keep them informed of when you will be in the room

 Descent through the pelvis  Engagement (tip of skull at level of ischial spines)  Flexion  Internal rotation  Extension  External rotation  Expulsion

An unengaged fetus at the onset of active labor (nulliparous women) is a risk factor for dystocia. 14% will be delivered by C-section. Williams Obstetrics, 2005

 THE PELVIS

 4 types pelvis shapes  Gynecoid is ideal ~ 50% have  Engaged is when the TIP of the skull is at the level of the ischial spines

Posterior

Anterior

 Dystocia: difficult labor; any labor deviation from normal labor pattern; difficult, prolonged, or abnormal labor  Mechanical Dystocia: due to passengerpassageway FIT problem
 Includes Pelvic Dystocia: pelvis too small or abnl shape  Related to a malpresentation (e.g., face or brow) or malposition (e.g., OT or OP)  Cord prolapse risk  Suspected protraction or arrest of dilatation and/or descent

To Mom

To Baby

 Fetus  Placenta  Umbilical cord

 Chorion/Amnion (membranes) and amniotic fluid (500-1500 mL)

1. Fetal lie: relationship of long axis of fetus to long axis of mother Longitudinal most common 2. Fetal attitude: pose assumed within the uterus Flexion most common Relationship of fetal body parts to each other 3. Presentation: portion of the fetus coming first Cephalic Breech Shoulder

Problems with passenger can be R/T:

      Fetal anomalies Presentation Position Size Multiple gestation Cord

Fetal anomalies
Fit issues

Photo from www.fetalhydrocephalus.com/hydro/Default.aspx

Cephalic (Fetal head is presenting) In addition, presentation can be classified according to attitude of fetal head and what is felt by the gloved fingers

Face/brow Transverse lie Breech

 Maternal Risk: C-section  Fetal Risk: cord prolapse  Treatment:

 External version
 Conscious sedation: Versed and Fentanyl  Possible use of Terbutaline (Brethine)

 C-section if version fails or fetus resumes breech presentation  4% of term fetuses are breech

Fetal position has a significant effect on (the) likelihood of cesarean delivery for both nulliparous and multiparous women and this effect is modified by fetal weight.
Herrick et al, 2009

From: www.getdoe.com

You palpate a firm, round form in the fundus, small parts on the womans right side, and a long, smooth, curved section on the left side. Based on these findings, the nurse should anticipate auscultating the fetal heart in which of the following?

1. 2. 3. 4.

A B C D

D C

 Macrosomia (4000 grams)  Often leads to cephalopelvic disproportion (CPD)  Treatment?

17 lb 1 oz Russian baby delivered by C-section

www.hoax-slayer.com/giant-Russian-baby.shtml

From: www.catalog.nucleusinc.com

Placenta Previa  Painless bleeding Placental Abruption  Usually pain  Thrombin - more contractions  Bleeding may be hidden  Constant and intermittent pain is possible  Assess location, rate pain, describe characteristics  Notify MD/DO ASAP  Start IV

Hidden (Occult)

Partial

Complete

 Call for help  Knee-chest or MODIFIED Trendelenburg  Sterile vaginal examination  No funic replacement  Digital displacement of little help  Avoid touching the cord

 Bladder inflation works (if you anticipate a delay to deliver)

 400 700 mL (use non-dextrose IVF)

 Start IV (If IV in, discontinue Pitocin, IV bolus)  STAY CALM!  If time, monitor the fetus and apply oxygen

Fig. 17-2

Hypotonic Uterine Contractions (Inertia)

     UCs become infrequent and palpate mild Slow progress Mechanical Dystocia? Exhausted mother and uterus? Infection?

Nursing :  If fetal well-being and low station, AROM (provider)  Oxytocin (Pitocin augmentation)  Ambulation does NOT work!  Hydrotherapy is nice but it is not the solution!

 Functional Dystocia: due to power problems

 Usually contractions are too few or too weak, i.e., inadequate power Nursing role: Notify the provider, document your assessment of uterine activity

Induction:
 Initiating labor by artificial means  Mechanical or medications to ripen the cervix  Oxytocin (Pitocin) after the cervix is ripe

Augmentation:
 Enhance weak and well-spaced contractions  Goal:  UC every 2-3 min x 40-60 seconds with interval of at least 1 minute and resting tone no greater than 25 mm Hg Pitocin is NOT the solution for mechanical problems

Fetal and Maternal Danger if: Contractions  < q 2 minutes  90 or more seconds  Peak pressure > 90 mm Hg  Resting tone 30 or more mm Hg FHR may not indicate severity of ischemia Role of the Nurse:  Decrease or discontinue oxytocin infusion  TITRATE DOWN or DISCONTINUE

Hypertonic Uterine Contractions

Latent Phase Spontaneous Hyperstimulation  Usually mild, frequent, and related to anxiety and/or herbs

 Nursing: antianxiety medication, IV bolus, warm bath, rest, pain control (Morphine sleep)
Latent Phase Tachysystole d/t Exogenous Prostaglandins or Oxytocin  May be related to cocaine use

Hypertonic Uterine Contractions

Active Phase  UCs too long, too close, too strong (MVUs), resting tone too high  uteroplacental perfusion deficit precedes fetal hypoxia, acidemia, acidosis, asphyxia  Fetal aspiration of meconium (not likely without fetal gasping after primary apnea, hypotension, and bradycardia)   maternal pain (decrease or DC Pitocin)  Breakthrough pain (epidural ineffective)  Blood in the urine? Consider fetal-pelvic fit and fetal position  Maternal Exhaustion, ineffective pushing

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POST PARTUM HEMORRHAGE  Blood loss of 500 mL or more  Especially if the uterus is infected after  A prolonged labor and/or  Excessive Pitocin administration

 Mechanical dystocia with inability of the fetus to pass through the mothers pelvis  Maternal conditions where pushing is harmful  Active maternal herpes or HIV

 Previous surgery on the uterus  Fetal compromise  Placenta previa or Placental abruption  Twins: vtx/breech, or breech/vtx

 Scheduled, Urgent, Emergent  Scheduled to preserve vaginal integrity, Scheduled: repeat C-section, breech, twins, other  Urgent : fetal condition likely to deteriorate (ASAP)  Emergency (STAT): no prep, no Foley (STAT) Foley, just go to the OR now; may be under a local if anesthesia is not in house  Psychological impact: anxiety, PTSD  Feelings of dependency/lack of control  Offer support, remember the family, especially if STAT C-section

Mother
 Anesthesia  Respiratory complications  Blood clots/DVT  Injury to urinary tract  Delayed intestinal peristalsis/ileus  Infection  Hemorrhage  Death

Neonate
 Inadvertent preterm birth  Respiratory problems because of delayed absorption of lung fluid  Injury

Copyright 2011 Learning Resources Intl., Inc.

Range BL Tachycardia Moderate Marked Bradycardia Moderate Marked Accelerations Decelerations Early Late Variable 120-160 bpm > 160 bpm 161-180 bpm > 180

Category 1 or Normal 2 - impending decompensation No atrial kick/ischemia and injury risk 2 or 3 Ischemia risk/low fetal BP With variability: 1/normal Without variability: 3/NR Head/brain compression Placenta: Hypoxia/Acidosis Cord Compression

100-119 bpm <100 bpm 15 bpm for 15 or more seconds Nadir depth from BL 10-40 bpm 5-60 bpm 10-60 bpm

 Discontinue oxytocin infusion  Reposition the patient (knee-chest is best, lateral is next best)  Oxygen at 10 L/minute by mask  IV bolus? (consider dangers)
 Myth: IV fluids to increase maternal volume  Fact: Release of atrial natriuretic peptide a smooth muscle relaxant

 Communicate: Charge nurse and CNM or MD/DO  SVE to check for a baby (vs. cord)  Consider route and timing of delivery

The End