Labor & Delivery

6-28-2009

~ Clinical Rotation Quiz ~
1. Discuss the four stages of labor and what happens in each stage. Define primigravida and multigravida and state how the stages are different for each.
Labor occurs in four stages, and may occur quicker in multigravida than in the woman who is primigravida. Primigravida women have only been pregnant one time; Multigravida women have been pregnant more than one time. The first stage of labor is the longest stage for both the multi and primigravida woman averaging 8 - 10 hours. This stage of labor begins with the onset of true labor and ends with the complete effacement and dilation of the cervix. The first stage is divided into 3 phases; latent, active and transitioning phases. The latent phase of labor is the first 3 cm of dilation of the cervix. This phase can be quite long, and may also be painless resulting in the woman not even realizing much of this phase. Changes that occur during this phase that include: fetal positioning changes, cervical effacement, dilation of up to 3 cm, and contractions that gradually increase in intensity, duration, and frequency, the contractions become about 5 minutes apart. Woman may have mild discomfort or pain during this phase, most often felt as low back-ache, or moderate intensity menstrual-like cramps. The laboring woman during this phase is usually quite excited, sociable, and cooperative, she is also anxious about the birth of her baby. The second phase of labor known as the Active phase is where the cervix dilates at a more rapid rate from 4 cm to 7 cm. This phase usually lasts on average 4.6 hours for the nullipara woman, and 2.4 hours for the multipara woman. The cervix becomes completely effaced, and the fetus has begun to descend into the pelvis. Contractions have become stronger, and are about 40 - 60 seconds in duration, they are also much more painful for the laboring woman during this phase. If she has chosen to receive an epidural or another type of pain medication this is the time she will be given it. The behavior of the woman changes also from excitement, to feeling of helplessness, anxiety, and she also becomes much more quiet, she is concentrating on the task at hand. The third phase or Transitional stage is usually very intense, but is also short in length, average time is 3.6 hours in the nullipara. The cervix is dilating from 8 cm to 10 cm, the fetus is descending further into the pelvis, contractions have become very strong and last from 60 - 90 seconds each. Contractions are usually 1.5 - 2 minutes apart in this phase. This phase is the most difficult phase, the woman may have nausea, vomiting, leg tremors, as well as being irritable. Women may also lose control of their behaviors during this phase if the pain is intense. Second stage of labor begins with the complete effacement and dilation of the cervix, and ends with the birth of the baby. This stage lasts 30 minutes to 3 hours in the nulliparous woman, and 5 - 30 minutes in the multipara woman. Contractions are still strong and are about 2 - 3 minutes apart, lasting 40 - 60

seconds each. The pressure on the pelvic floor caused by the decent of the fetus causes the mother to feel the urge to push. She may feel she needs to have a bowel movement at this time. As crowning begins the woman may feel stretching or tearing even if no trauma is occurring. Behavior of the laboring woman in this phase goes from uncontrolled to feeling more in control of the situation. She is sometimes not even aware of what is going on around her, she is solely focused on pushing the baby out. This stage demands intense physical exertion, and energy demands. Third stage of labor or the placental stage begins with the birth of the baby and ends with the placenta being expelled from the uterus. This is the shortest stage of labor, averaging 5 - 10 minutes, but up to 30 minutes. The uterus still contracts firmly but with minimal pain at this time, the woman is usually so excited at what she has just done and anxious to see her baby. The placenta separates from the uterine wall after birth due to the decrease in the size of the uterus, which also decreases the size of the placental site. After the expulsion of the placenta the uterus must contract firmly and remain contracted for the compression of open vessels to occur at the implantation site, otherwise the birth may result in hemorrhage and/or maternal demise. Fourth stage of labor occurs during the first 1 - 4 hours after birth. This stage includes the physical recovery of the mother and infant. Bonding between the mother and infant occurs, uterine contractions are still occurring to help control bleeding, some pain due to the mild contractions or traumas due to the birth may also be present. The woman is usually exhausted but finds it hard to sleep with all of the excitement, and eagerness to get acquainted with her new baby.

2.

Describe the 3 phases of a contraction. Define frequency, duration and intensity as it relates to the contraction.
The normal characteristics of contractions are coordinated, involuntary and intermittent. Contractions occur in three phases; increment, which occurs as the contraction begins in the fundus and spreads to the rest of the uterus; peak, where the contraction is the strongest or most intense; and decrement, which is the period of the contractions decrease in intensity, the uterus has begun to relax again. The contraction cycle is also described in terms of frequency, duration and intensity. Frequency is the time in between the start of 2 contractions, it is measured in minutes. Duration refers to the length of the contraction from the beginning to end. It is expressed in seconds. The intensity refers to the strength of the contraction(s), terms used to describe the strength are mild, moderate and intense.

3.

What is an epidural? State the nursing care for the client that has received an epidural.
An epidural is a regional analgesia and anesthesia that provides adequate pain relief without sedating the woman during labor and birth. The epidural block is best when started in women who are in active labor, as giving it prior to has been shown to slow the progress of labor. Epidural blocks are usually performed by an anesthesiologist or nurse anesthetist. A local anesthetic is injected into the small epidural space and is usually combined with opiod analgesics to provide substantial pain relief. The epidural is given via an epidural catheter that is inserted into the woman's L3 or L4 interspace, the catheter allows a continuous infusion of medication so that pain relief can be maintained during labor and birth. The epidural can also be individualized

depending on the level of pain relief the woman is wanting to achieve, the medication can also be given intermittently or by PCA. Nursing care of the woman who has received an epidural includes: recording maternal vital signs and FHR to use as a baseline to compare with vitals taken after the epidural is given, assessment of the woman's bladder must be done frequently as a full, distended bladder can inhibit the descent of the fetus, urinary catheterizations are performed as ordered, observing for signs and symptoms related to any adverse effects or catheter migration, and to ensure adequate intravenous access is in place with the proper fluids running at the correct rate.

4.

What are the two types of electronic fetal monitoring? Hint: External and Internal! When is each used? What conditions have to be present for internal monitoring?
The two types of electronic fetal monitoring are external and internal fetal monitoring. The external fetal monitor is commonly used during labor to assess the fetal heart rate and uterine activity. The external monitor is applied to the woman's belly and secured in place with an elastic belt, it usually needs to be readjusted to the correct position when the mother or fetus is active. No special conditions have to be present to use the external monitor, the woman just has to be pregnant. There are some factors that can affect the apparent intensity of a contraction: fetal size(small), abdominal fat thickness, position of the mother, and location of the transducer. Internal fetal monitoring is used for a more accurate assessment of the fetal heart rate and uterine activity. This monitor is an invasive device, and requires the membranes to be ruptured as well as at least 2 cm of cervical dilation. This type of monitor since it is invasive increases the risk of infections. Internal monitoring uses an electrode that is attached under the skin about 1 mm on the scalp of the fetus, but in a breech presentation it may be applied to the buttocks. The electrode only records the fetal heart rate, another device called an intrauterine pressure catheter is used to measure the uterine activity. This pressure catheter senses the changes in the intrauterine pressure, it is also sensitive enough to pick up intra-abdominal pressure changes as seen with coughing and/or vomiting.

5.

Give the normal ranges for the fetal heart rate. What is bradycardia and a possible cause? What is tachycardia and a possible cause?
The normal range of the fetal heart rate is from 110 - 160 bpm, and the rate is variable by the age of the fetus, premature fetuses of 26 - 28 weeks are at the higher end of the range due to the immature parasympathetic nervous system. Bradycardia is a fetal heart rate less than 110 bpm, that lasts for 10 minutes or longer. Possible causes of fetal bradycardia include: fetal head compression, fetal hypoxia, fetal heart block, fetal acidosis, compression of the umbilical cord, and/or late second-stage labor with maternal pushing. Tachycardia is a fetal heart rate more than 160 bpm for at least 10 minutes. Possible causes of fetal tachycardia: maternal dehydration, maternal fever, maternal or fetal hypoxia, maternal or fetal hypovolemia, maternal hyperthyroidism, fetal cardiac arrhythmias, severe maternal anemia, fetal

acidosis, or drugs that were given to the mother (decongestants, bronchodilators, or stimulant drugs).

6.

Define variability and baseline as they are related to the fetal heart rate. Why is variability important?
The fetal heart rate baseline is the average heart rate in two minutes, and then rounded to the nearest 5 bpm. The uterus must be at rest, between contractions, and there must not be any significant fluctuations in the rate with in the time it is being measured. Variability denotes the fluctuations in the baseline fetal heart rate that cause the printed paper to have an irregular rather than smooth appearance. Variability occurs because of the multiple factors that affect the fetal heart rate. Evaluating variability is important to help in determining how tolerant the fetus is of labor. Variability is used during electronic fetal monitoring because with adequate oxygenation the normal function of the autonomic nervous system is promoted which helps the fetus tolerate and adapt to the stresses of labor.

7.

Define decelerations. State the three major types of decelerations, possible causes and treatments for each.
The three types of decelerations are; early decelerations which are not associated with fetal compromise, and have a gradual decrease from the baseline FHR. These decelerations are thought to be caused by fetal head compression that normally occurs during a contraction, the deceleration should be no more than 30 - 40 bpm less than the baseline; late decelerations indicate a deficient exchange of oxygen and waste products in the placenta, these are non-reassuring patterns. If late decelerations are seen it indicates the fetus is intolerant of contractions during labor. The cause may be maternal hypotension, diabetes, or maternal hypertension. This type of deceleration usually start after the peak of a contraction with the FHR returning to the baseline after the contraction has ended; variable decelerations occur when flow is reduced in the umbilical cord. This type of deceleration may or may not occur during contractions, and rise and fall abruptly as the umbilical cord is compressed and then relieved. Variable decelerations last up to 15 seconds and decrease in the fetal heart rate is at least 15 bpm. Causes of variable decelerations may include: nuchal cord, prolapsed cord, oligohydraminios or other conditions causing insufficient blood flow in the umbilical cord.

8.

If a pattern of late decelerations is detected, what nursing actions should be initiated? If the deceleration does not improve, what action will probably be taken?
If late decelerations are seen or other non reassuring fetal heart rate patterns, the nurse should try to identify the cause, by evaluating the patterns, monitoring maternal vital signs, and perform a vaginal exam for evidence of a prolapsed cord. If oxytocin is being given via IV it needs to be stopped, fluids need to be increased to increase the mothers blood volume, the mother should be put in a non-supine position, give O2 by face mask at 8 - 10 L/min, start continuous electronic fetal monitoring if not already begun, notify the physician or mid-wife as soon as possible. If the late decelerations are severe the nurse and staff should prepare for immediate

delivery via cesarean section, the staff should include persons to resuscitate the neonate if needed.

9.

What is pitocin and when is it used in labor and delivery? How is it given and what nursing actions are necessary during its use? Why/how is it used after the delivery?
Pitocin also known as Oxytocin, is an identical synthetic compound to a natural hormone produced by the posterior pituitary. It stimulates smooth, uterine muscles, which results in increases in the strength, frequency, and duration of a contraction. It is used to induce or augment labor contractions at or near term. It is also used to help control and maintain postpartum bleeding, by stimulating the uterus to contract, which helps in compressing blood vessels. It can also be used to induce labor of an inevitable or incomplete abortion. Nursing actions needed during pitocin administration include: assessing fetal heart rate, maternal vital signs, observe for effective labor patterns by watching contraction frequency, duration, and intensity, and observe for hypo or hypertonic uterine contractions. The pitocin is usually given IV piggypack or by intramuscular injections. When pitocin is continued or given postpartum nursing actions should include: observing firmness of the fundus, as well as the height and deviation, massaging the fundus if boggy, watch for signs of hemorrhage, such as more than one peri-pad an hour and/or large clots. Monitor vital signs, intake and output, signs of cramping, breath sounds and for other signs of fluid retention.

10.

Define effacement and tell how it is measured. Define dilation and tell how it is measured. How do both of these indicate progress in labor?
Effacement is the thinning and shortening of the cervix that occurs during labor. It occurs because of the descending fetus which pushes down on the cervix making it shorten and thin. The nulliparous woman completes effacement earlier in the laboring process than the multiparous woman, because the multiparous woman has a thicker cervix. Measurement of cervical effacement is estimated as a percentage or the original cervical length, with a fully thinned cervix being 100% effaced. Dilation is the opening of the cervix that occurs during labor. 10 cm dilation is considered complete cervical dilation. The 10 cm dilation is sufficient enough to allow the passage of the full term fetus.

11.

What are some of the different types of analgesia given to the mother while she is in labor and how do these affect the fetus?
Labor and delivery includes a great deal of pain, and laboring women all deal with the pain differently. However most will want some type of pain relief, some of these analgesics include: Demerol, Fentanyl, and Nubain, these are opiod analgesics. The opiod analgesic Demerol given for pain relief may cause dysphoria rather than any significant effect on pain. This analgesic is also of concern because its metabolite normeperidine has a half-life of 15 - 23 hours in the newborn which can result in neonatal respiratory depression or low Apgar score. The opiod analgesics are usually given in frequent, small doses via IV, to ensure quick pain relief with a predictable duration of action, and it also reduces the risk of neonate respiratory depression. Other medications

such as, Phenergan are usually given with opiod analgesics to help relieve nausea and vomiting that is common when opiates are given. Phenergan can also add to the opiod's effect on respiratory depression. Sedatives such as barbituates may be given in small doses to help a fatigued, laboring woman rest, but these are not commonly given because of their prolonged depressant effects on the newborn.

12.

What is PIH and describe the treatments and care of the mother in labor with PIH?
PIH is pregnancy induced hypertension also known as preeclampsia. It is characterized by a systolic blood pressure of 140 mmHg and a diastolic of 90 mmHg that develops after 20 weeks gestation. It is also accompanied by proteinuria of > 0.3g collected in a 24 hour period, and random testing done by using a urine dipstick of ≥ 1+. Treatment and care of the intrapartum woman with PIH includes: administration of oxytocin to induce labor if not contraindicated, keeping the woman in a lateral position to promote placental circulation, pain relief should be well managed to help prevent the woman from getting agitated which can increase the blood pressure and thus increasing the risk for seizures, the woman must also be on seizure precautions (bed rails up, close monitoring of vitals, dim lights), Magnesium sulfate is given with the oxytocin in a secondary infusion to offset seizures from occurring, continuous electronic fetal monitoring should be initiated if not already, and during the birth a pediatrician, neonatologist, or neonatal nurse practitioner must be present to care for the newborn, a resuscitation team must also be ready if needed.

13.

What assessment and nursing care is given to the mother in the immediate recovery period after her delivery?
Care during the immediate recovery period following birth focuses on observing for hemorrhage and relief of any pain or discomfort. When observing for hemorrhaging it is important to assess the woman's vital signs, bladder for distention, amount and color of lochia, and uterine fundus. Assessment of the fundus should include the fundal height, firmness, and position, this should be assessed with each vital sign assessment. The fundus is one of the most important aspects to assess when observing for signs of hemorrhage, as it is the most common cause of excess bleeding in the post partum woman. If the uterus does not continue to contract firmly it inhibits the compression of blood vessels that are open at the placental separation site. During this exam, the fundus should be firm, midline, positioned below the umbilicus, and about the size of a large grapefruit depending on the normal anatomy of the woman and also if she was pregnant with multiple fetuses. Bladder distention can cause the uterine contractions to stop or slow, which can also lead to hemorrhaging. If distention is felt the woman should be given a bedpan so that she can empty her bladder, if she is unable to due to swelling of the urinary meatus related to trauma caused by birth she may need to be catheterized. The lochia should also be assessed each time vital signs are taken. The lochia should not exceed one peri-pad an hour immediately following birth, nor should it have any large clots. If either of these are noticed the physician should be contacted immediately. The perineum and labial areas should also be assessed for hematoma formation, and can be inhibited by application of ice packs to the areas. Comfort of the post partum woman is also important following birth. Ensure the woman has clean bedding, if they were soiled, ice packs for her perineal areas (some peri-

pads have ice packs in them which just need to be put in the freezer or fridge), she may also need to be given analgesics for afterpains common after birth. Nurses should instruct the woman to ask for pain medication prior to the pain level getting uncomfortable. It is common for women to be chilly after giving birth so ensuring they are warm by providing extra blankets and warm drinks. The nurse also allows privacy for the family so that the mother and father and if any siblings may start the bonding process. If the infant has a normal Apgar score the infant may be allowed to stay with the mother for its first assessment and bath (depending on the facilities policy). Mothers who have chosen to breastfeed are allowed to do so at this time, the sucking of the infant during breastfeeding stimulates oxytocin secretion which helps in contracting the fundus as well as maintaining the firmness of the fundus.

14.

What are the three main causes and treatments for postpartum hemorrhage?
Postpartum hemorrhaging is a leading cause of maternal demise. Three main causes include: Uterine atony which is responsible for about 80% of post partum hemorrhage. This condition is caused by the lack of uterine muscle tone resulting in the inability of the uterus to contract. Treatment for this condition includes massaging the uterus and expressing any clots that have accumulated, ensuring that the bladder is not full as this too may inhibit the uterus from contracting properly, administration of oxytocin may be given diluted in a rapid IV infusion to induce uterine contractions, if blood loss has caused blood pressure to fall Methergine may be given to help increase the blood pressure, if the oxytocin is not effective in controlling the uterine atony a drug named Prostin or Hemabate may be given IM or injected right into the uterine muscle. If bleeding is unable to be controlled arteries may have to be cauterized or even complete and radical hysterectomy. Trauma is the second common cause of post partum hemorrhage, and can include trauma to the vagina, cervix, as well as perineal lacerations or hematomas. Surgical repair is often needed for hemorrhaging caused by trauma. Subinvolution, which is the most dangerous due to the time period it happens, occurs 7 - 14 days after birth and is due to the delayed return of the uterus to its non-pregnant size, and fragments of the placenta that remained attached to the myometrium. Excessive bleeding occurs when the clots start to slough away several days after birth. This is the most dangerous post partum hemorrhage because the woman is unaware and unsuspecting of any complications this far after birth. Treatment is usually done immediately after birth by ensuring the placenta is intact once expelled, if it is not the physician or mid-wife may manually explore the uterus to locate the missing fragments, and then remove them. If this condition does occur and able to be treated, the treatment includes: controlling the bleeding by administering oxytocin, methylergonovine, or prostaglandins. Placental fragments are usually expelled with the bleeding, but a sonogram may be done to locate any placental fragments. If bleeding continues a D&C may be necessary to remove the fragments. Broad spectrum antibiotics are also given if infection is suspected.

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