First Stage of Labor
Begins with regular uterine contractions
Ends with full cervical effacement and dilation
They are safer at home!
First look at prenatal record!! What are glaring problems
First stage of labor
First stage of labor:
How do you recognize
Subjective or by palapation. Really subjective of how it feels though unless you have an internal.
Top of strip is fhr
Bottom is toco or contraction: frequency(start of one to the other), duration (how long) intensity-subjective or internal monitor
Expect contraction to start of further apart in latent phase: less frequency, duration shorter, intensity milder.
Active and transition- duration gets longer 90 seconds, minute of rest and another contraction, frequency decreases duration and intensity increases.
First stage: assessment, diagnoses
assessment and physical data
Assessment and nursing diagnosis
What else is in a physical exam
what do you assess regarding uterine contraction
labs done in first stage of labor
2 labs we do do is CBC and BLOOD TYPE
CBC platelets also important: if thrombocytopenic- that comes into play if she asks for an epidural: if it is below 100,000 then the anesthesiologic wont do it, cause she cant clot .
Look at crit, hemoglobin and thrombo
Ask, when do you think labor started, do you feel like you have broken your water, any vag bleeding???
+pooling or ferning confirms that she broke here water
GBS: test all women for it at 35-37 weeks.
2dose penicillin= adequate
Inadequate- less than 2 dosese, watch baby for 48 hours. Sepsis gbs protocol
plan of care/interventions for first stage of labor
change position every 30-60 min
tools needed for labor
All sterile, bulb, clamp , cut, basin, steile gloves
When head stays in perineum then you can open birth packet.
Second stage of labor
Infant is born
two phases of second stage of labor
what is ferguson reflex
preparing for labor
care managment- birth in delivery room
Birth in a delivery room or birthing room
Use of fundal pressure: contraindicated
Immediate assessments and care of newborn
perineal trauma in birth:lacerations
what are the degress of lacerations
types of perineal trauma in birth
Third stage of Labor: what happens
what is it
how many minutes
signs and symptoms
what is friedmans curve
average time it takes for birthing in first time moms vs. multiparious mothers.
-standard is that first time takes much longer
-Women today are heavier and older than then.
-People question it.
what is fourth stage of labor
key poiints: what environment is best in the first stage of labor
whos resonsibility is it for keeping track of womens progress in the first stage of labor
The nurse assumes much of the responsibility for assessing the progress of labor and for keeping the nurse-midwife or physician informed about that progress and deviations from expected findings
how do you know babe is in stress
a womens expectation or perception of birth
how to advance the progress of labor
LABOR AND BIRTH COMPLICATIONS
Preterm labor and birth
what is ptl
what is preterm birth
what is late preterm birth
▫Preterm labor (PTL): cervical changes and uterine contractions occurring at 20 to 37 weeks of pregnancy
▫Preterm birth: birth that occurs before the completion of 37 weeks (<37 0/7 weeks of gestation)
▫Focus on late preterm birth (34 weeks to 36 weeks 6 days)
Late preterm births: 34-36 6 weeks.
preterm labor vs braxton hicks: 4 contractions in 1 hour=labor, braxton hicks= unregular and random
what is spontaneous vs indicated
▫Spontaneous: 75% of preterm births
▫Indicated: 25% of preterm births :
-htn, low fluids, little growth,
▫Infection is the only definitive factor
how to predict spontaneous preterm labor
-Infection hx, lifestyle, past ob hx, preterm labors…
- hx of one, non white, genital tract colonization, mutifetal gestation, second trimester bleeding, low prepregnancy weight.
Not predictive of PTL or birth
But cervical length >30 mm unlikely to give birth prematurely
short cervix= maybe go into preterm labor.
▫Fetal Fibronectin (fFN)Test
fFN is a glycoprotein “glue” found in plasma and produced during fetal life.
-protein that acts like a glue- releases this when it starts to separate cervix- just signifies more likely that she will go into birth if the vaginal swab is +.
more of a "who will not go into labor" than who will
signs and symptos of preterm labor
contractions occuring more frequently than every 10 minutes persisty 1 or more hours
uterine contractions either painful or painless
lower ab cramping like gas, diarrhea
dull intermidden low back pain
painful mentrual like cramps
sujprapubocp pain or pressure
pelvic pressure or heavieness
discharge chang in character or amount of discharge, thicker or thinner, bloody brown colorness, smelly
rupture of membranes
what do you do in a preterm birth
-Preterm birth= wait and watch
PTL care managment
early recognition: what do you tell women to do?
▫Early recognition and diagnosis
▫Restriction of sexual activity: can cause labor due to prostaglandins!
ptl care managemtn
3 things you due as protective measures
▫Antenatal glucocorticoids: significantly reduce the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates
▫Fetal and early neonatal loss
Premature rupture of membranes
prom vs pprom
how long is it okay for membranes to be ruptured before we worry
what are the three things a rupture can cause that are important to know
- INFECTION risk. If the sack is gone= can be infecction. Longer the h20 is broken,= higher chance of infection.
- DON’T do exams if you don’t have to.
- Can go into spontaneous labor w.in 24 hours. Don’t want it to be >18 hours. Sometimes do an induction to get babes out.
- can cause Oligohyddraminos:not enough fluids, infection, prolapsed cord,
- DEFINITLY do a fetal assessment before they give them an okay before doing expectant managemet. Give them a time frame to see if they kik in to labor.
▫Responsible for 10% of all preterm births
▫Often preceded by infection
prom and pprom care management
What is the goal in PPROM
-Want baby to get to 34 wk.
-Fetal tachycardia= 1st sign of infeciton. Or decreased variability (minimal or absent), late decels
what is chorioamniotis
Post term pregnancy and birth and labor
maternal risks because of this
what happens to placenta at this time
risks for labor include
▫Dysfunctional labor and birth canal trauma
▫Labor and birth interventions more likely
▫Woman may experience fatigue and psychologic reactions as estimated date of birth passes.
At 42 weeks and beyond the placenta does not function as well. Gets old and dies off.
Fetal testing and sonagram to locate fluid.
Larger baby than you want! Dysfunctional labor- dystocia, more at risk for intervening.
maternal fetal risk of hemmorage and infection higher
fetal risks in postterm pregnancy and labor
▫Abnormal fetal growth (macrosomia) babe >4000 gram
▫Compromising effects on fetus of “aging” placenta
less calcium and other nutrients, less fluid leading to cord compression and fetal hypoxemia
care managment in POSTERM labor
▫Perinatal morbidity and mortality increase greatly after 42 weeks of gestation.
▫More frequent fetal assessment, testing
twice weekly testing and BPP or NST, amniotic fluid volume. most likely induce at 41 wk
▫Most common indication for c-birth
▫Five factors affect labor
dystocia sustpected when
risk factors in women
alteration in characteristics of uterine contractions, a lack of progress in rate of cervical dilation, or lack of progress in fetal descent and expulsion
womens risk factors
overweight, short, advanced maternal age, infertility, prior version, masculine, uterine bnormalities, malpresentations of fetus, cpd, uterine overstimulation, maternal fatigue, admin of analgesic too early
dystocia: abnormal uterine activity
▫Hypertonic uterine dysfunction (prodromal labor)
usually occur in the latent phase of first stage of labor, ucoordinated.
▫Hypotonic uterine dysfunction
Initially makes normal progress into the active phase of first-stage labor but then the contractions become weak and inefficient or stop
Calm uterus and start over.
Benedryl for sleep and rest
what other things can cause it?
▫Problems with bearing-down efforts, possibly due to epidural or analegesic
▫Friedman’s classification of “normal” labor patterns
▫Updated, evidence-based awareness of “normal” labor
▫Labor that lasts less than 3 hours from the onset of contractions to the time of birth
-Push down, not upwards -Holding breath is bad
-Don’t get fatigued.
-Slow babies the fluids are squeezed out= less fluid
-Precipitous labor= fluids arent squeezed out= laborous breathing in baby, more hemmorage inn mom.
birth occuring 3 hr or lesss
results from hypertonic uterine contractions, placental abrustipon, uterine tachysystoly or cocain
complications: uterine rupture, laceration of birth canal, amniotic fluid emborlism, pp hemmorage, shoulder dystosia, hypoxia, rapid birth causing intracranial trauma.
cause of dystocia
maternal and fetal
▫Cephalopelvic disproportion (CPD), also called fetopelvic disproportion (FPD)
-CPD- head and pelvis.
more cuase of dystociA
▫Maternal position alters relationship between uterine contractions, fetus, and mother’s pelvis
▫Hormones and neurotransmitters released in response to stress can cause dystocia
▫Sources of stress and anxiety vary
-Hard time monitoring cause of the extra tissue, hard to monitor babe.
-Use internal monitor
obstetric procedure- induction of labor
elective induction of labor
elective induction should not be initiated until when...
▫Labor is initiated without a medical indication.
▫Many are for the convenience of the woman or her primary health care provider.
Increased rates of cesarean birth
Increased neonatal morbidity
induction of labor: bishop score
what 5 things does the bishop score look at
▫A rating system used to evaluate inducibility or cervical ripeness
If less than 4 = not a great starting point- less of success of vaginal birth.
We like over 8 for vaginal delicery.
4 bishop score= not ready for pitocin, need a softening medication, miso or cervidel.
types of inductions of labor
▫Chemical agents: misoprostill porstaglandins, cervidil
▫Mechanical and physical methods
Cook catheter- one on uterine side and one vaginal and it compresses it.
▫Hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk let-down
Synthetic oxytocin (Pitocin) may be used either to induce labor or to augment labor that is progressing slowly because of inadequate
What is augmentation of labor
operative vag birth
other operative vag birth
Cesarean births overview
things to consider
Birth of a fetus through a transabdominal incision of the uterus to
preserve the well-being of the mother and her fetus
Cesarean birth rate in the United States has been over 32% since the early 2000s
VBAC = Vaginal birth after cesarean
TOLAC = Trial of labor after cesarean
-TOLAC- lets just try, if it doesn’t work- csectionàneed to be more cautious, liability, ob likes doing csections, more controlled.
things to consider
-Age, multi-fetal pregnacies, liability,
-Don’t induce before 39 weeks if not indicated, give them time to naturally birth.
-6cm is active labor.
csection surgical techniques and trials of labor
can you induce for vbac and tolac
-Rate of old scar opening up is 1% of all vbacs.
-Repeat csection increases to 2% if you have had multiple csections.
-Uterine scar is what matters.
-For vbacs we like low transverse incision.
-If it extends to the upper part of uterus, we don’t let vbac cause they are more at risk.
-Why did yu have csection/ breech, stall out labor, emergecy
-Must know HX so that we can predict.
-If breech, and planned c section, good vbac candidate
-If contracted pelvis that couldn’t fit baby, not really a candidate.
-Fof vbacs and tolacts- CANNOT INDUCE IF NOT IN LABOR because those meds can increase chancese of unterine rupture. Never induce a previous csection, but can augment- pitocin.
-Cant start the labor with meds though.
-Can mechanical ripening, foley, cook cath,
-Vbac- give less time too labor.
-2 hour push= p robably not, they wil have you csectin.
-Stalled with vbac- recommend repeat csection
-Success rate is 60-75%.
-3 times is max to cutting into uterus.
intraop csection care
blood loss vag bs. csection
300-500 ccs blood vaginal
types of obstetric emergencies
meconium stained fluid
mec stained fluid
▫Indicates fetus has passed stool prior to birth
Normal physiologic function of maturity
Umbilical cord compression
stressed out babe= mec
when babies head is born, what wont you see
what should you do as anurse
▫Head is born, but anterior shoulder cannot pass under pubic arch
▫Newborn more likely to experience birth injuries related to asphyxia- less o2, brachial plexus damage, and fracture
▫Mother’s primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or endometritis. Postpartum hemmorage and rectal injuries!
Brachial plexus- nerve damage near shoulder =erb palsy
Collar bone fracture- have to do this sometimes so baby can come out.
Don’t leave pt side, emergency –c all for help.
baby wont externally rotat, reatraction of fetal head against perineum called turtle sign happens
what to do: subrapubic pressure and maternal position changes, squqatting position, stay with women
what do you do
▫Occurs when cord lies below the presenting part of the fetus
▫Contributing factors include:
Long cord (longer than 100 cm)
Unengaged presenting part
-Prolaspsed cord : cord comes before babe.
-Sometimes when water breaks the fluid wooshes the water out
-Constant pressure- bradycardia – decels.
-Get fingers in and take pressure of of cord.
-Push head up so it is not sitting on cord.
what to do prolapsed cord pic
trendelenburg or knee chest
rupture of uterus
most frequent causes
▫Rare, serious obstetric injury; occurs in 1 in 2000 births
▫Most frequent causes of uterine rupture during:
Separation of scar of a previous classic cesarean birth
Uterine trauma (e.g., accidents, surgery)
Congenital uterine anomaly
bradycardia=loss of blood
rupture of uterus
during labor and birth common rupture reasons
▫During labor and birth
Intense spontaneous uterine contractions
Labor stimulation (e.g., oxytocin, prostaglandin)
Overdistended uterus (e.g., multifetal gestation)
Malpresentation, external or internal version
Difficult forceps-assisted birth
Occurs more in multigravidas than primigravidas
what is preterm labor defined as, how is it diagnoed, what is the cause
teaching to recognize preterm labor
using tocolytic therapy
signs of infection
key points: assisted births
vag after csection
Obstetric emergencies (e.g., meconium-stained amniotic fluid, shoulder dystocia, prolapsed cord, rupture of the uterus) occur rarely but require immediate intervention to preserve the health or life of the mother and fetus or newborn
what is the postpartum period
Postpartum (PP) period is the interval between birth and return of the reproductive organs to their nonpregnant state
reproductive system and structures
Immediately after birth, excessive bleeding can occur if bladder becomes distended
should void spontaneously 6-8 hr after birht
6 wks post birth=
lochia and fundal height
ovulation and menses postpartum
pregancny induced hypervolemia
nursing care for postpartum women
plan ffor discharge
pstpartum care managemetn
pp care management
pp care managment: psych
Family structure and functioning
follow up after discharge
key points: teaching, counseling, postpartum problems
1.Postpartum fatigue (PPF) is more than just feeling tired; it is a complex phenomenon affected by a combination of physiologic, psychologic, and situational variables. Which of these is not a contributing factor to PPF?
a.Long labor or cesarean birth
b.Infant care demands
c.Social isolation due to lack of visitors
d.Anemia or infection
C- Correct: Well-intentioned visitors can interrupt periods of rest both in the hospital or at home. Nurses may be asked to limit visitors and phone calls in order for the woman to rest. PPF is recognized as a risk factor for postpartum depression
Definition and incidence
Traditionally defined as follows:
Loss of 500 ml of blood after vaginal birth
Loss of 1000 ml after cesarean birth
A 10% change in Hct between labor and postpartum
casues of PPH
associated with what
more causes of pph
pph care managemete
Baloon bachle- cutting off all blood vessels. Filing it with normal saline. Keep in for 12 to 24 hrs.
pph care managemetn
types of postpartum infections
major cause of pp death
A physician orders methylergonovine (Methergine) 0.2 mg IM for a postpartum client. Which intervention should the nurse take prior to administering this medication?
a.Obtain the client’s blood pressure (BP).
b.Determine the client’s blood glucose level.
c.Take the client’s pulse.
d.Have the client empty her bladder.
Correct: Prior to administering Methergine, the nurse must check the client’s BP. If the BP is greater than 140/90 mm Hg, the medication should not be given. In either case, the nurse must continue careful monitoring of vaginal bleeding and uterine tone.
NEWBORN AND FAMILY CARE
care managemetn birth - 2hr
severely depressed, moderatly depressed, excellent condition
Know these and know how to score it.
To see if baby is transitioning well.
Normal hr- 110-160.
Under 100 needs ventilation- positive pressure- mask
Under 60 is neonatal recucitation
Grimace is like muscle tone- flexing, sneezing coughing crying reacting to touch. (usually com out flexing)
Flaccid= no grimace or activity
Appearance: usualy pinkish blueish. Usually use o ne for color- acrocyanosis- extremities (get one point for that). DO NOT LIKE Central cyanosis.
Respirations: blue, retractions, nasal flaring, fluid in lungs, grunting
Is it using lungs, and becoming an air breather?? Transition to air breathing abe
Bulb suction – always suction mouth first- because they can aspirate, and then nose
Assessment birth through 1st two hours
classification by gestation
care mangemetn high risk infant
parental adaptation to hgigh risk infant
problems in infants postbirth
Care of the infant with a birth injury is individualized based on the type of injury
common newborn problems
screening tests for babies after birth
interventions for new babies
neonatal infections interventions types
immunizations and surgeries for newborn
-moms-petroilum over it, to help healing and keep it from sticking to diaper
-Clean with warm water- no soap and lotions, petrolium wrap cream so it doesn’t stick to diaper.
-Bleeding make sre thaey are not, espeically if no vit. K done
-Yellow formation on penis is normal, don’t wipe it off, it builds over to help heal
-Babt needs to pee normall!
-6-8 wet diapers/24 hrs
neonatal pain managemnt
pharamacleogic and nonpharm
parent infant interaction assessment
discharge planning nad teaching
discharge planning and teaching
Prior to discharging a male infant who has just been circumcised, the nurse must evaluate that the parents understand the instructions for care at home. The nurse is reassured when the parents report which of the following?
1.They will check for bleeding with every diaper change.
2.The baby is expected to void at least four times in 24 hours.
3.Soap and water should be used to clean the penis.
4.They will notify the provider if a yellow exudate develops and covers the head of the penis.
A Correct: Bleeding needs to be evaluated at every diaper change. If bleeding occurs, gentle pressure should be applied with a sterile gauze square. If the bleeding does not stop, the primary health care provider should be notified.
B Incorrect: The baby should void after the circumcision prior to discharge. He is expected to void six to eight times within 24 hours.
C Incorrect: The penis should be cleansed with plain water and petroleum applied. Soap should not be used until the circumcision is healed at 5 or 6 days after the procedure.
D Incorrect: This is normal and will remain for 2 to 3 days. The parents should not attempt to remove this exudate. Redness, swelling, or discharge indicates infection, and the physician should be notified.
risk of artifical breast milk
nBreastfeeding was the method of infant feeding
nArtificial feeding attempted early in history
nDangers of artificial feeding
nWet nurses popular
AAP breastfeeding recomendations
nExclusive breastfeeding for about the first 6 months
nThen begin “solids” and continue breastfeeding until 12 months or longer as mutually desired by mother and child.
benefits of breastfeeding to mom
nPromotes uterine involution, less bleeding PP
nReturn to pre-pregnancy weight more quickly
nDecreases risk for breast cancer and rheumatoid arthritis
nProvides some protection against development of osteoporosis
contraindications to breastfeeding
nIllicit drugs use
nActive and untreated tuberculosis
nDiagnostic or therapeutic radioactive isotopes
nActive herpes simplex lesions on the breast
nGalactosemia in infant
nHIV positive (in USA & developed countries)
nCytomegalovirus (CMV) with preterm infants
nSome rare medications
lactation supply demand
nProlactin - Primary hormone responsible for lactation (milk production) released from anterior pituitary
nOxytocin - Let-down reflex (milk ejection) released from posterior pituitary
after birth breastfeeding time
nEarly (first hour) and Frequent (minimum 8 times day) Feeding/Pumping/Hand Expression
n1st Choice: Baby
n2nd Choice: Hand Expression
n3rd Choice: Hospital Grade Breast Pump
nResearch shows that baby/milk expression within 1 hour of birth increases milk production at 1, 3, & 6 weeks
why are breasts smart?
nBaby suckles at breast
nBreast is emptied
nBreast “realizes” it needs to make more milk
nHormones cause increased supply for next feeding
nBottle is offered instead of breast or no feeding/pumping offered
nBreast is NOT emptied
nBreast “realizes” it doesn’t need to make milk
nHormones cause decreased supply for next feeding
trends in breast feeding
nBreast milk Banks: Breast milk as “medicine”for preterm infants
nInformal Milk Sharing
nHand Expression http://newborns.stanford.edu/Breastfeeding/HandExpression.html
baby friendly steps to breastfeeding
nBaby-Friendly Ten Steps to Successful Breastfeeding
1.Have a written breastfeeding policy that is routinely communicated to all health care staff.
2.Train all health care staff in skills necessary to implement this policy.
3.Inform all pregnant women about the benefits and management of breastfeeding.
4.Help mothers initiate breastfeeding within 1 hour of birth.
5.Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6.Give newborn infants no food or drink other than breast milk, unless medically indicated.
7.Practice “rooming in”— allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9.Give no pacifiers or artificial nipples to breastfeeding infants.
10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic
skin to skin
nGI Microbiome- want goo dbacteria to be present in gut