Management of DiscomfortChapter 19

Nonpharmacologic StrategiesCutaneous Stimulation StrategiesCounterpressure *Effleurage (light massage) *Therapeutic touch & massage *Walking *Rocking *Changing positions *Application of heat or cold *Transcutaneous electrical nerve stimulationAcupressureWater therapy (hydrotherapy)Intradermal water block

Nonpharmacologic StrategiesSensory Stimulation StrategiesAromatherapyBreathing techniques *Music *Imagery * Use of focal points *

Nonpharmacologic StrategiesCognitive StrategiesChildbirth education *HypnosisBiofeedback

First Stage of LaborSystemic analgesiaOpioid agonist analgesicsOpioid agonist-antagonist analgesics, co-drugsEpidural (block) analgesia Combined spinal epidural (CSE) analgesiaParacervical block (rarely used)Nitrous oxide

Second Stage of LaborNerve block analgesia / anesthesiaLocal infiltration anesthesiaPudendal blockSpinal (block) anesthesiaEpidural (block) analgesiaCombined spinal-epidural (CSE) analgesiaNitrous oxide

Vaginal BirthLocal infiltration anesthesiaPudental blockEpidural (block) analgesia / anesthesiaSpinal (block) anesthesiaCombined spinal epidural (CSE) analgesia / anesthesiaNitrous oxide

Cesarean BirthSpinal (block) anesthesiaEpidural (block) anesthesiaGeneral anesthesia

Nsg. Assessments (Fetal)Prior to med administration:FHR within normal range (no late decels or nonreassuring patterns).Average long term variability.Present short term variability (with spiral electrode).Normal fetal movements.Accels with fetal movement.Term fetus. (EDC)

Nsg. Assessments (Maternal)Prior to med administration:Term pregnancy (EDC).Evaluation of cervical dilation.Evaluation of contraction pattern.Evaluation of maternal comfort.Med allergies.Empty bladder.

Nsg. Assessments (Additional)Prior to med administration:A well established contraction pattern.Fetal presenting part is engaged.Cervix dilated.Delivery should be anticipated but not imminent.

Concerns: Regional AnesthesiaMaternal hypotension, and subsequent fetal distress. *Adverse maternal reactions. (can range from palpitations to complete cardiovascular collapse).Uteroplacental insufficiency.

Frequent monitoring of maternal vital signs & FHR are needed!

Fetal Assessment During LaborChapter 20

Assessment for Genetic Disorders Maternal ageEthnic backgroundFamily historyReproductive historyMaternal diseaseEnvironmental hazards Chapter 22

Strategies in Health Education and Counseling Frame teaching to match the clients perceptionFully inform clients of the purpose and expected effectsBe specificUse a combination of strategiesInvolve othersReferMonitor progress through follow-up contacts Chapter 22

BIOPHYSICAL PROFILE (BPP)A noninvasive assessment of the fetus and its environment by U/S, noting normal and abnormal biophysical responses to stimuli.A normal BPP indicates that the CNS is functional and the fetus is not hypoxemic.A scoring system, of 5 variables, with a total score up to 10.

Biophysical Profile Variables Fetal breathing movementsGross body movementFetal toneAmniotic fluid volume indexNon-stress test Chapter 22

BPP: VARIABLES & SCORESFETAL BREATHING MOVEMENTS:>1 episode in 30 min, each > 30 seconds. (normal score = 2)Episodes absent or no episode > 30 sec in 30 min. (abnormal = 0)GROSS BODY MOVEMENTS:>3 discrete body or limb movements in 30 min. (normal = 2)< 3 episodes of body or limb movement in 30 min. (abnormal =0)

FETAL TONE:> episodes of active extgension with return to flexion of fetal limb(s) or trunk, opening & closing hand being considered normal tone. (normal =2)Slow extension with return to flexion, movement of limb in full extension, or fetal movement absent. (abnormal = 0)

REACTIVE FETAL HEART RATE:> 2 episodes of acceleration (>15 bpm) in 20 min, each lasting > 15 sec. & associated with fetal movement. (normal = 2)< 2 episodes of acdceleration or acceleration of < 15 bpm in 20 min. (abnormal = 0)

QUALITATIVE AMNIOTIC FLUID VOLUME:> 1 pockets of fluid measuring >1 cm in 2 perpendicular planes. (normal =2)Pockets absent or poscet < 1 cm in 2 perpendicular planes. (abnormal = 0)

Interpretation of BPP Scores:Normal = 8-10 (if Amniotic fluid index is adequate)Equivocal = 6Abnormal =

Documentation of a Contraction Stress Test Negative: No late decelerations with 3 adequate uterine contractions in a 10-minute window, normal baseline FHR and accelerations with fetal movement.

Positive: Late decelerations occur with more than half the uterine contractions.

Chapter 22

Documentation of a Contraction Stress Test (cont.)Suspicious: Late decelerations occur with less than half the uterine contractions.

Unsatisfactory: Inadequate fetal heart rate recording or less than 3 uterine contractions in 10 minutes.

Chapter 22

Indications for the NST Suspected post-maturityMaternal diabetesMaternal hypertension: chronic and pregnancy-related disordersSuspected or documented IUGR History of previous stillbirthIsoimmunization

Chapter 22

Indications for the NST (cont.)Older gravidaDecreasing fetal movement Sever maternal anemiaMultiple gestationHigh-risk antepartal conditions: PROM, PTL, bleedingChronic renal diseases

Chapter 22

Electronic Fetal MonitoringExternal: ultrasound transducerInternal: spiral electrode

Ultrasound TransducerHigh-frequency sound waves reflect mechanical action (fetal heart tone & valves) of the fetal heart.Noninvasive. (Does NOT require rupture of membranes or cervical dilation)Used in both antepartum and intrapartum period.Short-term variability and beat-to-beat changes in the FHR cannot be assessed accurately by this method.

Spiral ElectrodeApplied to the fetal presenting part to assess the FHR.Converts the fetal ECG as obtained from the presenting part to the FHR via a cardiotachometer.Used ONLY when membranes are ruptured & cervix is sufficiently dilated.Short-term variability CAN be assessed using this method.

FHR VariabilityIncreased Variability: marked variability from a previous average variability.Causes: early mild hypoxia; fetal stimulation (uterine palpation, contractions, fetal activity; maternal activity; illicit drugs).Significance: unknown.Nsg.Intervention: observe for any nonreassuring patterns; if using external fetal monitoring consider an internal mode for a more accurate tracing.

FHR VariabilityDecreased Variability: marked decrease in variability from a previous average variability.Causes: hypoxia / acidosis; CNS depressants; analgesics / narcotics; barbiturates; tranquilizers, anaractics; parasympatholytics; general anesthetics; prematurity (

FHR VariabilityDecreased Variability (continued):Significance: benign when associated with fetal sleep cycles; if drugs, variability usually increases as drugs are excreted; when associated with uncorrectable late decelerations indicates presence of fetal acidosis and can result in low APGARs.Nsg.Interventions: none, if fetal sleep cycle, or CNS depressants; consider fetal scalp stimulation or apply a spiral electrode; monitor fetal oxygen saturation; prepare for birth if indicated.

Other DEFINITIONSTachycardia: a baseline FHR >160 bpm for a duration of 10 minutes or longer.Bradycardia: a baseline FHR

FHR ChangesAccelerationsDecelerationsEarlyLateVariableProlonged

Baseline FHRDefinition: the average rate during a 10 minute period that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 bpm.Range: 110-160 bpm.

AccelerationsDefinition: A visually apparent abrupt increase in FHR above the baseline rate.An increase of 15 bpm and lasting 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration.Can be periodic or episodic.

Early DecelerationsDefinition: a transitory gradual decrease and return to baseline FHR in response to fetal head compression.Generally starts before the peak of the uterine contractions.Returns to the baseline at the same time as the contraction returns to its baseline.Considered benign. No interventions.

Late DecelerationsDefinition: a transitory gradual decrease in and return to baseline of FHR associated with contractions.Begins after the contraction has started, and the lowest part of the decel occurs after the peak of the contraction.Usually does NOT return to baseline until after the contraction is over.Indicates uteroplacental insufficiency. Interventions required!Considered ominous sign when theyre uncorrectable, especially when associated with decreased variability and tachycardia.

Late DecelerationsInterventions:Change maternal position (lateral)Correct maternal hypotension (elevate legs)Increase rate of maintenance IVD/C oxytocin if infusingAdminister O2 at 8-10 L/min (face mask)Fetal scalp or acoustic stimulationAssist with fetal O2 saturation if orderedAssist with birth if pattern cannot be corrected.

Variable DecelerationsDefinition: an abrupt decrease in FHR that is variable in duration, intensity,and timing related to onset of contractions; caused by umbilical cord compression.Onset to the beginning of the nadir is 15 bpm, lating >15 seconds; variable times in contracting phase; often preceded by transitory acceleration.Return to baseline is rapid and

Variable DecelerationsInterventions:Change maternal position (side to side).If severe:D/C oxytocin if infusingAdminister O2 at 8-10 L/min (face mask)Assist with vag or speculum examIf cord is prolapsed, examiner will elevate fetal presenting part with cord between gloved fingers until c/s is accomplishedAssist with amnioinfusion if orderedAssist with fetal O2 saturation monitoring if orderedAssist with fetal O2 saturation if ordered

Prolonged DecelerationsDefinition: a visually apparent decrease in FHR below the baseline 15 bpm or more and lasting more than 2 minutes but less than 10 minutes.Benign causes: pelvic exam, application of spiral electrode, rapid fetal descent & sustained maternal valsalva maneuver.Other causes (severe): progressive severe variable decels, sudden umbilical cord prolapse, hypotension, paracervical anesthesia, tetanic contraction & maternal hypoxia (may occur with seizure).

Nursing Care During LaborChapter 21

QUESTIONS TO ASK LABORING CLIENT:UTERINE CONTRACTIONSTime of onset: What was the time of the 1st ctx, & at what time did the ctx.become regular?Frequency: How often do the ctx. occur?Duration: How long do the ctx.last?

Intensity: What is the level of pain? Describe the nature & location of the pain?Effect of Ambulation: do the ctx.become more or less frequent and intense with ambulation?ADDITIONAL HISTORY:Bloody show: What was the frequency & amt.of discharge?Vaginal bleeding: What was the amount, color, and consistency?

Membranes: Is there leaking or have you experienced spontaneous rupture of membranes? What was the amont, color, consistency, & time of occurrence?Fetal Activity: Has the fetus moved or kicked since labor began?Nutrition, hydration, and sleep: When was the last time you ate, drank, or slept?Social support available: Is someone with you?

General emotional well-being: Are you relaxed? Are you using breathing techniques? (can also be observed).Transportation: Is transportation to the birth site available?

MONITORING DURING LABOR:Purpose = to determine that maternal-fetal status is within normal limits during labor and that maternal status is within normal limits in the immediate postpartum period; to intervene when deviations from normal are noted.

Assess the following parameters during the 1st and 2nd stages of labor at regular intervals:Vital signs: BP on admission & at least hourly during the active phase of labor (more frequently if elevated or epidural). T-P-R on admission & q4hr (more frequently if ROM or elevation).Fetal well-being: auscultate & record FHR on admission or place on EFM for 20-30 min. Use continuous or intermittent monitoring depending on maternal-fetal risk.

Uterine activity: Assess & record frequency, duration, and intensity of uterine ctx q30-60 minutes by direct palpation or through interpretation of electronic fetal monitoring strips.Labor progress: perform a vag.exam to assess cervical effacement & dilatation, fetal position & station, & status of membranes. (use Friedmans curve).I & O: ensure adequate hydration. Initiate IV fluid as needed or before administration of epidural. Encourage to empty bladder frequently.

HOW LABOR PROGRESS IS MEASURED:Contraction pattern.Cervical consistency & effacement. Cervical changes.Cervical dilatation.Station.

WAYS TO FACILITATE LABOR PROGRESS:Work with ctx.rather than against them. Encourage relaxation between ctx. Assist in paced breathing techniques, focus, visual imagery, ambulation, change position regularly, good communication with nurse & support person.

PSYCHOSOCIAL ASSESSMENT IN LABOR:Support system.Level of understanding of labor process & procedures.Effectiveness of coping strategies to deal with labor process & pain of level.

The psychosocial assessment provides the basis for education of the patient, anticipatory guidance, and provision of supportive care including both pharmacologic & nonpharmacologic measures

LABORATORY DATA:URINE: test for protein, ketones, glucose, WBCs, nitrates (should all be negative).HEMATOCRIT & HEMOGLOBIN: HCT

SEROLOGIC TESTS FOR SYPHILIS (VDRL): samples may be obtained on admission, depending on institutional policy. Results should be negative.HEPATITIS B SURFACE ANTIGEN: repeat test if antepartum results are > 30 days old.Rh FACTOR & ABO TYPING: necessary during the antepartum period, and pp when indicated.

PROMOTING A NORMAL CHILDBIRTH:Maintain an awareness and appreciation of the individuality of each womans labor.Be aware of cultural differences related to labor and birth.Update your knowledge on intrapartum research topics (stay current).

Become reenergized by meeting and sharing with other professionals who work with the same challenges & issues. Join specialty organizations.Know your professional standards of practice. These form your basis for safe practice.Advocate for womens needs on the basis of your knowledge of safe practice.Be aware of your biases regarding labor and birth.

POSSIBLE NURSING DX:FIRST-STAGE LABOR:Knowledge deficit: lack of information related to expected physical changes, symptoms of labor, and options available to the childbearing woman.Pain related to the process of labor or birth.Anxiety related to childbirth, pelvic examinations, or obstetric interventions.Fear related to parenting.

Fluid volume excess related to intake during labor.Altered nutrition: less than body requirements related to decreased intake during labor.SECOND-STAGE LABOR:Fear related to birth process, pain, and unknown outcome.Fatigue related to physical exertion during labor and lack of sleep.Pain related to fetal descent, crowning, and perineal stretching.

THIRD- AND FOURTH-STAGE LABOR:Risk for infection related to uterine placental site, episiotomy incision, and fatigue.Urinary retention related to loss of sensation to void and rapid bladder filling.Ineffective breastfeeding related to maternal knowledge deficit, anxiety, or fatigue.

Friedmans CurveEmanuel Friedman began work in 1950s, and over 20 years defined the phases and length of the stages of labor for nulliparous and multiparous women.His work showed that cervical dilatation & fetal descent follow a predictable pattern & appear as an S curve when plotted on a graph.Analysis of labor progress is plotted on a graph (a partograph).

Can be used to plot cervical dilatation and fetal descent on the graph, and if labor begins to slow in comparison to the average rate of progress defined by Friedman, and this data can provide a basis for decision making about the progress of a womans labor.Friedmans work is the most universally accepted scientific treatment of labor & is nationally used in normal labor, and to diagnose dystocia (abnormal labor) when deviations are apparent.

LEOPOLDS MANEUVERS:Purpose: to provide information about fetal presentation, position, presenting part, lie, attitude, and descent.Can aid in location of fetal heart tones, assessment of fetal size, and determination of single vs multiple gestation.Used in late 2nd trimester or 3rd trimester, when fetal parts can be felt through abdominal wall.

******* Forms of care that are considered likely to be beneficial.** Forms of care that are considered likely to be beneficial.** Forms of care that are considered likely to be beneficial.*******Narcan is always available for use if delivery is precipitous, and infant is depressed.*****The fetal response to hypoxia is:Alteration in movement, muscle tone, breathing and heart rate patterns.

BPP is an accurate indicator of impending fetal death.Fetal acidosis can be diagnosed early with a nonreactive nonstress test and absent fetal breathing movements.An abnormal BPP score and oligohydramnios are indications that labor should be induced.Fetal infection in women who have ROM prior to 37 weeks, can be diagnosed early by changes in biophysical activity that precede the clinical signss of infection and indicate the necessity for immediate birth.******Safety of U/S Diagnostics:In the >30 years of use, no conclusive evidence of any harmful effects on humans has emerged.It is believed, the benefits to the patient and the fetus, far outweigh possible risks.******CAUTION:May pick up maternal pulse. Always double check by palpating maternal radial pulse.May be used with multiples.Standard paper speed is 3 cm/min.Once the area of maximal intensity of the FHR has been located, conducive gell is applied to the surface of the ultrasound transducer, and the transducer is then positioned over this area.

FHR VARIABILITY: irregular fluctuations in the baseline FHR of 2 cycles per minute or greater.Short-term = beat-to-beat. Only assessed with an internal or spiral electrode.Long-term = rhythmic waves or cycles from baseline. Overall changes. The big picture.In practice, they are generally viewed together to determine fetal well-being.

4 Ranges of variability: Based on visualization of the amplitude of the FHR in the peak-to-trough segment in beats per minute and includesAbsent or undetected variability. Non-reassuring pattern.Minimal variability (greater than ndetected but not more than 5 beats per minute).Moderate variability (6 to 25 beats per minute).Marked variability (greater than 25 beats per minute.

*Electrode penetrates into fetal presenting part by 1.5 mm and must be attached securely to ensure a good signal.*Illicit drugs: specifically cocaine and methanphetamines.

Non-reassuring patterns: include decreasing variability and late decelerations.***Tachycardia:Considered a sign of early hypoxemia (especially when associated with late decelerations and minimal or absent variability).Can result from maternal or fetal infection (prolonged rupture of membranes with amnionitis); maternal hyperthyroidism or fetal anemia; or in response to drugs such as atropine, hydroxyzine (vistaril), terbutaline, or illicit drugs such as cocaine or methamphetamines.

BRADYCARDIA:Must be distinguished from prolonged deceleration patterns.Can be considered a later sign of fetal hypoxia and is known to occur before fetal death.Can result from placental transfer of drugs; compression of the umbilical cord; maternal hypothermia, maternal hypotension.Maternal supine hypotension syndrome caused by the weight and pressure of the gravid uterus on the vena cave, decreases the return of blood flow to the maternal heart, which then reduces maternal cardiac output and blood pressure.*PERIODIC CHANGES:Are those that occur with uterine contractions.EPISODIC CHANGES (NONPERIODIC CHANGES):Those that are not associated with uterine contractions.*FHR is determined by the central nervous system, and the fetal autonomic nervous system.

An increase in sympathetc response results in acceleration of the FHR.

An augmentation in parasympathetic response produces a slowing of the FHR.

Usually a balanced increase of sympathetic and parasympathetic response occurs during contractions, with no observable change in the baseline FHR.**DECELERATIONS:Caused by dominance of parasympathetic response.May be benign or nonreassuring.Described by their visual relationship to the onset and end of a contraction and by their shape.

Other CAUSES:During contractionsDuring vaginal examinationsAs a result of fundal pressureDuring placement of the internal mode of fetal monitoring

Usually occur during the first stage of labor when the cervix is dilated 4-7 cm.Sometimes seen during the second stage when the woman is pushing.Generally U shaped.*LATE DECELS:Usually indicate the presence of fetal hypoxemia stemming from insufficient placental perfusion.Associated with fetal hypoxemia progressing to hypoxia and acidemia progressing to acidosis.Nponreassuring pattern is associated with fetal hypoxemia, acidemia, and low Apgar scores.Generally repeatative.Rarely decelerates