Intrapartum Assessment and interventions ch 8 Flashcards
Intrapartum Period
The intrapartum period begins with the onset of regular uterine contractions (UCs) and lasts until the expulsion of the placenta. The process by which this normally occurs is called labor. Childbirth is the period from the conclusion of the pregnancy to the start of the infant’s extrauterine life
Labor Triggers
Generally, it is proposed that labor is triggered by both maternal and fetal factors that may be caused by an inflammatory process, a genetic component, and/or biomarkers in cervicovaginal fluid. Unfortunately, even with substantial research, there is no concrete evidence of how labor initiates or what mechanisms are triggered at the time of labor. There is some evidence that the myometrium is stimulated by prostaglandins and oxytocin (biochemical factors) and becomes active. This initiates more contractions that become synchronized and softening of the cervix, which was previously protective
Labor: Maternal Factors
Uterine muscles are stretched to the threshold point, leading to release of prostaglandins and oxytocin that stimulate contractions.
● Increased pressure on the cervix stimulates the nerve plexus, causing release of oxytocin by the maternal pituitary gland, which then stimulates contractions.
● Estrogen increases, stimulating the uterine response. ● Progesterone, which has a quieting effect on the uterus, is withdrawn, allowing estrogen to stimulate contractions.
● Oxytocin stimulates myometrial contractions. Oxytocin and prostaglandin work together to inhibit calcium binding in muscle cells, raising intracellular calcium levels and activating contractions.
● The oxytocin level surges from stretching of the cervix.
Labor:Fetal factors
● As the placenta ages, it begins to deteriorate, triggering initiation of contractions.
● Prostaglandin synthesis by the fetal membranes and the decidua stimulates contractions.
● Fetal cortisol, produced by fetal adrenal glands, rises and acts on the placenta to reduce progesterone that quiets the uterus and increases prostaglandin that stimulates the uterus to contract.
Signs of impending labor
A few weeks before labor, changes occur that indicate the woman’s body is preparing for the onset of labor. These changes are also referred to as premonitory signs of labor.
● Lightening: This refers to the descent of the fetus into the true pelvis approximately 2 weeks before term in first-time pregnancies. The woman may feel she can breathe more easily but often experiences urinary frequency at this stage from increased bladder pressure. In subsequent pregnancies, this may not occur until labor begins.
● Braxton-Hicks: These contractions are irregular UCs that do not result in cervical change and are associated with “false labor.” Braxton-Hicks contractions are usually not painful, don’t happen at regular intervals, don’t get closer together, may stop with a change in activity or position, and do not feel stronger over time. These contractions begin to coordinate the many muscle layers of the uterus to perform when true labor begins. True labor is characterized by regular uterine contractions that result in progressive dilation and effacement of the cervix and fetal descent into the pelvis
● Cervical changes. The cervix ripens, becomes soft, and may become partially effaced and begin to dilate. The woman may lose her mucous plug or have a change in discharge.
● Nesting. Some women experience a burst of energy or feel the need to put everything in order, which is sometimes referred to as nesting.
● Less commonly, some women experience a 1- to 3-pound weight loss and others experience diarrhea, nausea, or indigestion preceding labor. ● The woman may experience low backache and sacroiliac discomfort due in part to the relaxation of the pelvic joints.
● The woman may experience a brownish or blood-tinged cervical mucus discharge referred to as bloody show.
Factors affecting labor; 5 P’s
Labor is defined by UCs that bring about effacement and dilation of the cervix. Factors that have been traditionally identified as the essential components in the outcome of labor and delivery include the 5 “P’s”
● Powers (the contractions)
● Passage (the pelvis and birth canal)
● Passenger (the fetus)
● Psyche (the response of the woman)
● Position (maternal postures and physical positions to facilitate labor)
Powers
Powers refers to the involuntary UCs of labor and the voluntary pushing or bearing-down powers that combine to propel and deliver the fetus and placenta from the uterus (
myometrial and decidual oxytocin receptors fluctuate during pregnancy. By the third trimester, the myometrial receptors increase by more than 300%, while uterine sensitivity of oxytocin also increases.
Though no theory has been proven correct, studies support that pacemaker cells in the uterus send signals to other cells (Sultatos, 1997) and that the posterior lobe of the pituitary gland secretes oxytocin to stimulate contractions
Uterine Contractions
● The uterine muscle, known as the myometrium, contracts and shortens during the first stage of labor. Synchronizing of these muscles focuses on the uterus & adnexa, partially due to the cervical dilation and lower uterine segment thinning
● The upper segment composes two-thirds of the uterus and contracts to push the fetus down.
● The lower segment composes the lower third of the uterus and the cervix and is less active, allowing the cervix to become thinner and pulled upward.
● Uterine contractions are responsible for the dilation (opening) and effacement (thinning) of the cervix in the first stage of labor.
● Uterine contractions are rhythmic and intermittent.
● Each contraction has a resting phase or uterine relaxation period that allows the woman and uterine muscle a pause for rest. This pause allows blood flow to the uterus and placenta that was temporarily reduced during the contraction phase. It is during this pause that much of the fetal exchange of oxygen, nutrients, and waste products occurs in the placenta. With every contraction, 500 mL of blood leaves the utero–placental unit and moves back into maternal circulation thus ridding the utero-placental unit of waste and bringing in a replenished oxygen supply.
● Uterine contractions are described in the following ways (Fig. 8–2):
● Frequency: Time from beginning of one contraction to the beginning of another. It is recorded in minutes (e.g., occurring every 3 to 4 minutes). ● Duration: Time from the beginning of a contraction to the end of the contraction. It is recorded in seconds (e.g., each contraction lasts 45 to 50 seconds).
● Intensity: Strength of the contraction. It is evaluated with palpation using the fingertips on maternal abdomen and is described as:
● Mild: The uterine wall is easily indented during contraction.
● Moderate: The uterine wall is resistant to indentation during a contraction.
● Strong: The uterine wall cannot be indented during a contraction.
● There are three phases of a contraction (see Fig. 8–2):
● Increment phase: Ascending or buildup of the contraction that begins in the fundus and spreads throughout the uterus; the longest part of the contraction. ● Acme phase: Peak of intensity but the shortest part of the contraction.
● Decrement phase: Descending or relaxation of the uterine muscle.
● Contractions facilitate cervical changes (Fig. 8–3A, B, C).
● Dilation and effacement occurs during the first stage of labor when UCs push the presenting part of the fetus toward the cervix, causing it to open and thin out as the musculofibrous tissue of the cervix is drawn upwards (see Fig. 8–3B).
● Dilation is the enlargement or opening of the cervical os.
● The cervix dilates from closed (or <1 cm diameter) to 10 cm diameter (see Fig. 8–3C). ● When the cervix reaches 10 cm dilation, it is considered fully or completely dilated and can no longer be palpated on vaginal examination.
● Effacement is the shortening and thinning of the cervix (Fig. 8–3A, B, C).
● Before the onset of labor, the cervix is 2 to 3 cm long and approximately 1 cm thick (Fig. 8–3A).
● The degree of effacement is measured in percentage and goes from 0% to 100%.
● Effacement often precedes dilation in a first-time pregnancy. Effacement and dilation progression of the cervix occurs together in subsequent pregnancies.
Bearing down powers
Bearing-down powers occur once the cervix is fully dilated (10 cm), and the woman feels the urge to push; she will involuntarily bear down. The urge to push is triggered by the Ferguson reflex, activated when the presenting part stretches the pelvic floor muscles. Stretch receptors are activated, releasing oxytocin and stimulating contractions.
The bearing-down powers are enhanced when the woman contracts her abdominal muscles and pushes. Multiple studies in the last 20 years have shown significant evidence that maternal fatigue is less and the abnormal FHR tracings associated with closed glottis sustained pushing are decreased when the woman pushes, with no significant increase of the second stage of labor.Studies done in the late 1990s and early 2000s demonstrated less injury to the pelvic floor and perineal injuries with pushing.
spontaneous pushing had no adverse fetal effects, higher maternal satisfaction, and no significant change in labor duration. Interventions in the second stage of labor should be realized independently with consideration of the situation at hand. It is important to consider the duration of pushing, parity, epidural analgesia, adequacy of pushing efforts, maternal and fetal status and progress, as well as the woman’s preferences
Mother initiated spontaneous pushing
Mother-initiated, spontaneous pushing in the second stage of labor begins at the time the woman feels the urge to push. Spontaneous pushing is defined as a mother’s response to a natural urge to push or a bearing-down effort that comes and goes several times during each contraction. It does not involve timed breath holding or counting to 10. Scientific evidence supports spontaneous physiologic approaches to a second stage labor management. However, most women in the U.S. receive instructions from care providers to use prolonged Valsalva bearing-down efforts as soon as the cervix is completely dilated. Delaying bearing-down efforts during the second stage of labor until the woman feels the urge to push results in optimal use of maternal energy, has no detrimental maternal or fetal effects, and results in improved fetal oxygenation. Though most commonly used with woman who receive epidural anesthesia, laboring down is just one component of physiologic second stage labor care that can be used to achieve optimal maternal and neonatal outcomes.
Active Direct pushing
Active-directive pushing: Women historically have been put in the lithotomy position and given instructions to take a deep breath, hold it, and bear down with a closed glottis for at least 10 seconds, at least three times during one contraction as soon as they were complete, regardless of whether they felt the urge to push.
Physiologic second stage labor care(laboring down)
Physiologic second-stage labor care (laboring down): Encourage the women to wait until she feels an urge to push to initiate spontaneous bearing-down efforts. Support them in bearing down in response to natural urges. This passive descent is followed by an active urge to bear down.
Evidence based practice info
Waiting to push based on the woman’s physical and emotional readiness has been recommended for decades Having women labor upright in comfortable positions and not in the lithotomy position or on their backs has shown improved fetal oxygenation and APGAR scores.
Passage
The passage includes the bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and introitus (external opening to the vagina). Although all these anatomical areas play a role in the birth, the e maternal pelvis is the greatest determinate in the vaginal delivery of the fetus. The assessment of the size and shape of the pelvis is important. Assessment of the pelvis is performed manually through palpation with a vaginal exam by the care provider during pregnancy.
Pelvis
● Types of bony pelvis (Fig. 8–4): ● Gynecoid (most common type and found in about 50% of women)
● Android
● Anthropoid
● Platypelloid (least common type and found in about 3% of women)
● The anatomical structure of the pelvis includes the ileum, the ischium, pubis, sacrum, and coccyx (Fig. 8–5). ● The bony pelvis is divided into:
● False pelvis, which is the shallow upper section of the pelvis.
● True pelvis, which is the lower part of the pelvis and consists of three planes, the inlet, the midpelvis, and the outlet. The measurement of these three planes defines the obstetric capacity of the pelvis.
● The pelvic joints include the symphysis pubis, the right and the left sacroiliac joints, and the sacrococcygeal joints.
● The actions of the hormones estrogen and relaxin during pregnancy soften cartilage and increase elasticity of the ligaments, allowing room for the fetal head.
● Station refers to the relationship of the ischial spines to the presenting part of the fetus and assists in assessing for fetal descent during labor (Fig. 8–6). Station 0 is the narrowest diameter the fetus must pass through during a vaginal birth.
Soft tissue
● The soft tissue of the cervix effaces and dilates, allowing the descending fetus into the vagina.
● The soft tissue of the pelvic floor muscles helps the fetus in an anterior rotation as it passes through the birth canal.
● The soft tissue of the vagina expands to allow passage of the fetus.
Passenger
he passenger is the fetus. The fetus and its relationship to the passageway are the major factors in the birthing process. The relationship between the fetus and the passageway is affected by the fetal skull, fetal attitude, fetal lie, fetal presentation, fetal position, and fetal size. At the onset of labor, the position of the fetus with respect to the birth canal is critical, when a fetus is in a position other than cephalic (head first), a cesarean delivery is considered. Size of the fetus alone is less significant in the birthing process than the relationship among fetal size, position, and pelvic dimensions
Fetal Skull
fetal head usually accounts for the largest portion of the fetus to come through the birth canal.
● Bones and membranous spaces help the skull to mold during labor and birth.
● Molding is the ability of the fetal head to change shape to accommodate/fit through the maternal pelvis
fetal skull is composed of two parietal bones, two temporal bones, the frontal bone, and the occipital bone (Fig. 8–8A).
● The biparietal diameter (BPD), 9.25 cm, is the largest transverse measurement and an important indicator of head size (see Fig. 8–8B).
● The membranous space between the bones (sutures) and the fontanels (intersections of these sutures) allows the skull bones to overlap and mold to fit through the birth canal
Fetal attitude or posture
Fetal attitude or posture is the relationship of fetal parts to one another, noted by the flexion or extension of the fetal joints.
● At term, the fetus’s back becomes convex and the head flexed such that the chin is against the chest. This results in a rounded appearance with the chin flexed forward on the chest, arms crossed over the thorax, the thighs flexed on the abdomen, and the legs flexed at the knees.
● With proper fetal attitude, the head is in complete flexion in a vertex presentation and passes more easily through the true pelvis.
Fetal Lie
Fetal lie refers to the long axis (spine) of the fetus in relationship to the long axis (spine) of the woman.
● The two primary lies are longitudinal and transverse (Fig. 8–10 A&B).
● In the longitudinal lie, the long axes of the fetus and the mother are parallel (most common).
● In the transverse lie, the long axis of the fetus is perpendicular to the long axis of the mother.
● A fetus cannot be delivered vaginally in the transverse lie.
Presentation
● Cephalic (head first) (Fig. 8–11A)
● Breech (pelvis first) (Fig. 8–11B)
● Shoulder (shoulder first)
Presenting part
The presenting part is the specific fetal structure lying nearest to the cervix. It is determined by the attitude or posture of the fetus. Each presenting part has an identified denominator or reference point used to describe the fetal position in the pelvis.
● Cephalic presentations: The presenting part is the head (Fig. 8–12).
● This accounts for 95% of all births
● The degree of flexion or extension of the head and neck further classifies cephalic presentations.
● Vertex presentation indicates that the head is sharply flexed and the chin is touching the thorax. The denominator is the occiput.
● Frontum or brow presentation indicates partial extension of the neck with the brow as the presenting part. The denominator is the frontum.
● Face presentation indicates that the neck is sharply extended and the back of the head (occiput) is arching to the fetal back. The denominator is the mentum-chin.
● Breech presentations: The presenting part is the buttock and/or feet
● Complete breech: Complete flexion of the thighs and the legs extending over the anterior surfaces of the body
● Frank breech: Complete flexion of thighs and legs
● Footling breech: Extension of one or both thighs and legs so that one or both feet are presenting
● Transverse presentation: The presenting part is usually the shoulder
This usually is associated with a transverse lie.
● Compound presentation: The fetus assumes a unique posture usually with the arm or hand presenting alongside the presenting part.
Fetal position
The fetal position is the relation of the denominator or reference point to the maternal pelvis
There are six positions for each presentation: right anterior, right transverse, right posterior, left anterior, left transverse, and left posterior.
The occiput is the specific fetal structure for a cephalic presentation
The sacrum is the specific fetal structure for a breech presentation
The acromion is the specific fetal structure for a shoulder presentation
The mentum is the specific fetal structure for the face presentation
Position is designated by a three-letter abbreviation
● First letter: Designates location of presenting part to the left (L) or right (R) of the woman’s pelvis ● Second letter: Designates the specific fetal part presenting: occiput (O), sacrum (S), mentum (M), and shoulder (A) ● Third letter: Designates the relationship of the presenting fetal part to the woman’s pelvis such as anterior (A), posterior (P), or transverse (T)
Psyche
A woman’s experience and satisfaction during the labor and birthing process can be enhanced by coordination of collaborative goals between the woman and health care personnel in the plan of care. This influences her self-esteem, self-confidence, relationship to others, and general view of life. During her pregnancy, the woman should confer with her provider about pregnancy-related changes and what to expect in labor. By looking at how she handles pain, stress, anxiety, and what her preferences are, she can then make a plan of action to maintain control and autonomy when in labor. Encourage the woman to identify comforting items (such as pictures, music, visualization techniques, a favorite gown, and support people) to provide solace in the hospital environment
Factors that influence the woman’s coping mechanism include her culture, expectations, a strong support system, and type of support during labor.
Culture
The nurse must be culturally aware and sensitive to the needs and practices of the individual by integrating the woman’s cultural and religious values, beliefs, and practices to provide a mutually acceptable plan of care.
Culture and Birth tradition
Culturally sensitive communication is open, respectful, and nonjudgmental, and acknowledges that the nurse is willing to learn
Giving birth is a pivotal life event, and the meaning of birth and parenthood is culturally defined
Culture influences all aspects of a woman’s response to labor and impacts factors such as:
● Who is with the woman in labor, their role, and who participates in decision making
● Preferences for use of pharmacological and non-pharmacological pain management in labor ● Who the woman wants to care for her in relation to gender and modesty
● Response to labor
The nurse must consider these factors to help women formulate their concerns, priorities, and decisions during childbirth.
It is important for nurses to have a general understanding of birth practices of the cultural groups prevalent in the area where they work
it is essential in the delivery of quality and safe care to childbearing women and their families.
By identifying the patient’s beliefs and being sensitive to her experiences of the health care system, nurses can provide individualized care to the women and her support system and give helpful information and guidance when differences are encountered.
Strategies for nurses:Improving culturally responsive care in labor and Birth
Ethnicity, race, and religion may influence a woman’s values, practices, and preferences during labor and birth. A flexible approach to care is required to meet the individualized needs of the woman during labor and birth. Nurses should be knowledgeable of the customs and beliefs of the specific cultural groups receiving care.Providing individually focused, culturally sensitive care may enhance the likelihood of a positive birth experience. This may include the following measures:
● Learn the traditions of the cultural groups you often care for and the specific preferences of each woman and her family.
● Recognize there are subcultures within cultures.
● Listen to the woman and her support persons and help them find meaningful and acceptable support activities.
● Identify who the client calls “family.” ● Expectations for the role of the woman’s partner regarding support behaviors during labor and birth may vary greatly from one culture to the next.
● Use the beliefs, values, customs, and expectations of the woman to shape her plan of care for labor and birth.
● Include notes on cultural preferences and family strengths and resources as part of all intake and ongoing assessments and nursing care plans. ● Instead of focusing on technology, look beyond the routine and appreciate the needs of each woman.
● Develop linguistic skills related to your patient population. ● Learn to use nonverbal communication in an appropriate way.
● Learn about the communication patterns of various cultures.
● Recognize and acknowledge your own belief system while maintaining an open attitude.
● Examine the biases and assumptions you hold about different cultures. ● Avoid preconceptions and cultural stereotyping.
● Recognize all care is given within the context of many cultures.
● Advocate for organizational change that is flexible to cultural variations.
Expectations for birth experience
The nurse should review the woman’s expectations to help alleviate fear and to help set realistic goals.
● Unrealistic expectations can cause an increase in maternal anxiety. ● Past experiences and complications of pregnancy, labor, and birth strongly influence women’s expectations of labor and response to labor.
● Women who have experienced a negative previous birthing experience are at risk for increased anxiety; women who experienced a positive previous birthing experience have lower anxiety levels.
● Women who are recent immigrants may have had very different birth experiences in other countries, and that influences their expectations, hopes, and fears.
● Current pregnancy experience with difficulty conceiving, an unplanned pregnancy, or a high-risk pregnancy may increase a woman’s anxiety and fears.
Nursing support of laboring women
continuously available labor support from a registered nurse (RN) is a critical component to achieve improved birth outcomes. The RN assesses, develops, implements, and evaluates an individualized plan of care based on each woman’s physical, psychological and socio-cultural needs, including the woman’s desires for and expectations of the laboring process. Labor care and labor support are powerful nursing functions and it is incumbent on health care facilities to provide an environment that encourages the unique patient-RN relationship during childbirth. For women in labor, continuous support can result in the following:
Shorter labor
• Decreased use of analgesia/anesthesia
• Decreased operative vaginal births or cesarean births
• Decreased need for oxytocin/uterotonics
• Increased likelihood of breastfeeding
• Increased satisfaction with the childbirth experience
Non-pharmacologic methods of supporting and comforting women in labor have been shown to be therapeutic and to impact on women’s experiences and birth outcomes.
continuous support during labor may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labor, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score, and negative feelings about childbirth experiences.
Support system
The woman’s perception of being able to maintain control during labor and delivery is an important contributing factor to a positive and favorable evaluation of childbirth. This includes control of pain perception, control over emotions and actions, and being able to influence decisions while being an active participant. the patient experiences decreased anxiety and feels more in control.
Nursing care of women in early or latent labor should incorporate the following types of support and interventions:
● Encourage her to do normal, distracting activities and rest as needed. ● Provide emotional support, including continuous presence, reassurance, and praise.
● Provide information about labor progress and advice regarding coping techniques.
● Offer comfort measures (e.g., comforting touch, massage, warm baths/showers, promoting adequate fluid intake and output).
● Serve as an advocate, including assisting the woman in articulating her wishes to others.
Supportive Care for adolescents in labor
Supportive Care for Adolescents in Labor Adolescents may have a very different view of labor and birth as they struggle with self-identity and self-esteem. It can pose a challenge for providers and nurses to work with adolescents to promote a positive birthing experience, and they must understand adolescent development, expectations, and needs to do so. According to Sauls (2010), four themes became apparent based on feedback of over 180 adolescents in three tertiary centers during their postpartum interviews:
• Respectful nurse caring: During interactions, be kind and friendly and make her feel welcome. Include her in decision making, informing her of her options related to her care.
• Assistance with pain control: Assist her with pain management options with explanations of both pharmacological and non-pharmacological choices. Assess often her ability to manage her pain.
• Nursing support of the adolescent’s support person: Pay attention to her support person’s emotional and physical needs. Encourage them as they work through labor, including them in explanations and plan of care discussions.
• Childbirth guidance: Orient her and her support system to hospital facilities and to the birthing process, anticipating questions and explaining procedures. Answer questions truthfully and in an age-appropriate manner.
Nurses should establish environments in which adolescents’ rights are protected.
Pregnant adolescents often require special care and attention during the second stage of labor. The young adolescent has fewer coping mechanisms, less experience to draw on, incomplete cognitive development, fewer problem-solving capabilities, and an ego identity that is more easily threatened by the stress and discomfort of labor. Interventions that support the normal physiologic processes of the second stage of labor should be age- and developmentally appropriate for adolescents.
Adoptive parents
the birth plan must consider issues surrounding labor support, who will be with the birth mother, and the extent of the adoptive parents’ involvement in the labor and after birth. When preparing the birth plan, birth mothers should be asked if they want the prospective adoptive parents to be present for the birth, whether in the waiting room or in the labor room itself, or whether they prefer the adoptive parents remain at home during labor and birth.
Commonly, birth mothers decide to have some time alone at the hospital. This gives them a chance to feel settled in the decision and make peace before placement.
Supporting the wishes of the birth mother is the priority and duty of the nurse caring for the laboring woman. The experience of birth and the moments after belong to the birth mother, and nurses must allow the birth family to have their time. When the adoptive parents will have contact with the newborn is the birth mother’s decision in most situations.
Because society views the relinquishment of an infant as a voluntary choice, there may be no acknowledgment that a loss has occurred, and thus no expectation for the birth mother to go through a grief process with subsequent adjustment. Relinquishing mothers value and need someone who will support them and their interests at this vulnerable point in their lives. The attitudes of the health care provider can affect how much control the relinquishing mother has over the adoption process. . Nurses involved with women at the time of relinquishment can be of significant help in the resolution of grief.. Postpartum telephone calls and/or support groups may be beneficial in this area. Referrals for long-term counseling may be needed.
Gestational surrogacy
The practice of gestational surrogacy involves a woman known as a gestational carrier who agrees to bear a genetically unrelated child with the help of assisted reproductive technologies for an individual or couple who intend(s) to be the legal and rearing parent(s), referred to as the intended parent(s.Although gestational surrogacy increases options for family building, this treatment also involves ethical, medical, psychosocial, and legal complexities that must be considered to minimize risks of adverse outcomes for the gestational carrier, intended parent(s), and resulting children.
Generally, the surrogate accepts responsibility to maintain the pregnancy and perform conventional measures for fetal growth until the child is born. In surrogacy, families have a business agreement surrounding the pregnancy and birth, so multiple families are involved in the hospital stay.State laws surrounding these arrangements vary and are evolving, and clear policies and procedures that outline the legal processes are needed.
Nurses are integral for a smooth process of care and to promote satisfaction for the surrogate and intended parents. Surrogacy arrangements surrounding the birth are typically detailed as part of a surrogacy contract. However, regulation and standards are changing and current knowledge of relevant hospital and legal standards is essential to provide care for surrogate families. Everyone involved in surrogacy may need early and ongoing support, education, care options, and counseling.Remember the gestational surrogate is the patient and is always the nurses’ primary concern. When the adoptive parents have contact with the newborn is the decision of the birth mother in most situations.
Labor Support
Concerns about the consequent dehumanization of women’s birth experiences have resulted in demands for a return to continuous, one-to-one support by women for women during labor .
Two complementary theoretical explanations have been offered for the effects of labor support on childbirth outcomes. Both explanations hypothesize that labor support enhances labor physiology and woman’s feelings of control and competence.
First theory: During labor, women may be uniquely vulnerable to unfamiliar environmental influences; current obstetric care frequently subjects women to institutional routines, high rates of intervention, unfamiliar personnel, and lack of privacy, resulting in stress.
These conditions may have an adverse effect on the progress of labor and on the development of feelings of competence and confidence; this may in turn impair adjustment to parenthood and establishment of breastfeeding and increase the risk of depression.
● This response may, to some extent, be buffered by the provision of support and companionship during labor.
● Second theory describes two pathways: enhanced passage of the fetus through the pelvis and soft tissues, and decreased stress response.
● Enhanced feto-pelvic relationships may be accomplished by encouraging mobility and effective use of gravity, supporting women to assume their preferred positions, and recommending specific positions for specific situations.
● Studies of the relationships among fear and anxiety, the stress response, and pregnancy complications have shown that anxiety during labor is associated with high levels of the stress hormone epinephrine in the blood, which may lead to abnormal fetal heart rate (FHR) patterns in labor, decreased uterine contractility, a longer active labor phase with regular well-established contractions, and low Apgar scores.
● Emotional support, information and advice, comfort measures, and advocacy may reduce anxiety and fear and associated adverse effects during labor.
● Anxiety (a sense of uneasiness in response to a vague unspecific threat) can interfere with labor and increase nausea and crying, as well as interfering with the ability to focus. Emotional factors can contribute to the experience of increased pain due to high levels of anxiety
● Fear (a painful, uneasy feeling in response to an identifiable threat) can be fear related to the unknown, fear of injury to self and fetus, or fear of pain. Fear can decrease UCs and enhance the perception of pain. Procedures and an unfamiliar environment can result in a sense of loss of control and feeling of helplessness. Women in labor can feel abandoned.
Preexisting expectations and fear itself elicits a request for c-section, predisposing the woman to higher levels of pain.
Nurses can help and support women to be actively involved in their own care by allowing time for discussion, listening to worries and concerns, and offering information to help women gain increased self-determination in the context of care.
● Psychosocial factors may also influence a woman’s ability to cope and anxiety levels. If she has poor coping skills and high anxiety, she may experience increased pain. Positive expectations on the part of the woman correlate to better pain relief and labor responses.
Position
Discussion of the influence on labor includes a fifth “P,” maternal position during labor and birth. The woman’s position affects both anatomical and physiological adaptations to labor
Position is now more accurately referred to as freedom of movement during labor, allowing the woman to labor in the position she finds most comfortable. Registered nurses are integral to this process: they suggest alternatives and support the woman in choosing positions that are most conducive to her individualized needs and tailored to her current stage and phase of labor. Walking, moving, and changing positions are all important options to facilitate freedom of movement.
Resting places other than beds, such as rocking chairs and birthing balls, may be suggested. RNs provide advice, support, and encouragement to women to empower them to take advantage of the full range of options during labor.
Registered nurses should be knowledgeable about positioning techniques for women with epidural analgesia, and they play a key role in supporting position changes that facilitate the birth process, promote maternal comfort, and maintain patient safety.
Freedom of movement
● Freedom of movement should be an option for women since it is known to enhance the ability of some women to cope with the pain of labor. Using a variety of positions makes it easier for the woman to work with her body and with the fetus as the fetus moves through the pelvis.
During the first stage of labor, an upright position (walking, sitting, kneeling, or squatting) and/or a lateral position is encouraged .
● These positions are used to decrease the compression of the maternal descending aorta and ascending vena cava that could result in a compromised cardiac output. Compression of these vessels can lead to supine hypotension, resulting in decreased placental perfusion.
● The upright position has shown benefits of aiding in the descent of the infant and more effective contractions that result in shorter labor as well as decreasing the need for pain medication, oxytocin, and mechanical-assisted deliveries. Being in an upright, squatting, or side-lying position also demonstrated less severe lacerations or need for episiotomies.
● Frequent position changes are associated with a reduction of fatigue, an increase of comfort, and improved circulation to both mother and fetus.
● Maternal position in the second stage of labor can impact the natural urge to push. Upright positions provide the advantage of gravity to help the mother move the fetus through the pelvis, and gravity-neutral positions may be more relaxing. Upright positions include standing, kneeling, and squatting. Gravity-neutral positions include side-lying and hands-knees.
● During the second stage of labor, the upright position has been shown to increase the pelvic outlet and better aligns the fetus with the pelvic inlet.
● The position most used in births in the United States is the lithotomy position, which allows for provider visualization and control during the delivery process.
Onset of labor
As the woman comes closer to term pregnancy, the uterus becomes more sensitive to oxytocin and the contractions increase in frequency and intensity.
True labor vs false labor
True labor contractions occur at regular intervals and increase in frequency, duration, and intensity
● True labor contractions bring about changes in cervical effacement and dilation.
● False labor is characterized by irregular contractions with little or no cervical change.
Assessment of rupture of membranes
Spontaneous rupture of the membranes (SROM) may occur before the onset of labor but typically occurs during labor. Once the membranes have ruptured, the protective barrier to infection is lost, and ideally the woman should deliver within 24 hours to reduce the risk of infection to herself and her fetus.
Different techniques may be used to confirm rupture of membranes (ROM): ● A speculum exam may be done to assess for fluid in the vaginal vault (pooling).
● Ferning: During a sterile speculum exam, a sample of fluid in the upper vaginal area is obtained, placed on a slide, and assessed for “ferning pattern” under a microscope (Fig. 8–19A). A ferning pattern confirms ROM.
● AmniSure testing kit: The AmniSure ROM Test is a rapid, non-invasive monoclonal immunoassay that detects PAMG-1, an amniotic protein that appears in vaginal secretions if ROM has occurred. This aids clinicians with the diagnosis of ROM in pregnant women with signs and symptoms suggestive of the condition. According to published data it is ~99% accurate.
● Nitrazine paper: The paper turns blue when in contact with amniotic fluid. Can be dipped in the vaginal fluid or fluid-soaked Q-tip can be rolled over the paper (Fig. 8–19B). This method is no longer common.
Nursing actions
● Assess the FHR.
● There is an increased risk of umbilical cord prolapse with ROM. ● There is a higher risk of umbilical cord prolapse when the presenting part is not engaged.
● Assess the amniotic fluid for color, amount, and odor.
● Normal amniotic fluid is clear or cloudy with a normal odor that is similar to that of ocean water or the loam of a forest floor.
● Fluid can be meconium-stained; this must be reported to the care provider as it may indicate fetal compromise in utero.
● Document the date and time of SROM, characteristic of fluid, and FHR.
Guidelines for going to birthing facility
A general rule of thumb for first-time pregnancy with no risk factors is to wait until contractions are 5 minutes apart, last 60 seconds, and are regular for at least an hour. The woman should go to the birthing center immediately when: ● The membrane ruptures, or water breaks.
● She is experiencing intense pain.
● Bloody show increases.
Emergency Medical Treatment and Active Labor Act
The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal regulation enacted to ensure treatment for a woman seeking care in an emergency or if she thinks she is in labor, regardless of her ability to pay. Nurses who work in the labor and delivery unit(s) of the hospital need to be familiar with EMTALA regulations . In general, the criteria for admission to the hospital for labor are cervical dilation to 3 to 4 cm and/or ruptured membranes.
Mechanism of labor
The positional changes in the presenting part required to navigate the birth canal constitute the mechanism of labor. These mechanisms are cardinal movements of labor
Engagement
● Engagement: When the greatest diameter of the fetal head passes through the pelvic inlet; can occur late in pregnancy or early in labor
Descent
● Descent: Movement of the fetus through the birth canal during the first and second stages of labor
Flexion
Flexion: When the chin of the fetus moves toward the fetal chest; occurs when the descending head meets resistance from maternal tissues; results in the smallest fetal diameter to the maternal pelvic dimensions; normally occurs early in labor.
Internal Rotation
● Internal rotation: When the rotation of the fetal head aligns the long axis of the fetal head with the long axis of the maternal pelvis; occurs mainly during the second stage of labor
Extension
Extension: Facilitated by resistance of the pelvic floor that causes the presenting part to pivot beneath the pubic symphysis and the head to be delivered; occurs during the second stage of labor
External rotation/restitution
● External rotation/restitution: During this movement, the sagittal suture moves to a transverse diameter and the shoulders align in the anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis.
Head and shoulders rotate to move under the symphysis pubis
Expulsion
● Expulsion: The anterior shoulder usually comes first followed by the remainder of the body.
