Maternity Nursing Lecture Notes

NURSING 222 LECTURE NOTES 

       TOPIC  

       PAGE 

Lecture 1 

Introduction to Maternity Nursing   

   2 

Lecture 2 

Uncomplicated Labor & Delivery 

 10 

Lecture 3 

Analgesia & Anesthesia   

 34 

Lecture 4   

Nursing in the Normal Puerperium   

 41 

Lecture 5 

Nursing Care of the Normal Newborn 

 53 

Lecture 6   

High Risk Newborn 

 69 

Lecture 7 

Uncomplicated Pregnancy 

 88 

Lecture 8   

Fetal Assessment & Pregnancy at Risk 

107 

Lecture 9   

Pregnancy at Risk #2 

129 

Lecture 10   

Complications of Labor & Delivery   

140 

Lecture 11   

Complications of the Puerperium 

158 

Lecture 12   

Disorders of the Female & Male Reproductive    

168 

System 

Lecture 13   

Infertility & Genetics 

190 

CSM Maternity Nursing

Lecture 1

I.

Intro to Maternity Nursing

A.

Role of the Perinatal Nurse

a. Scope of nursing practice determined by: -Calif State Nursing Practice Act-BRN -Community standards

-Policy and Procedure of facility

-JCAHO-Joint Commission on Accreditation of Healthcare Organizations

-Dept. of Health Services

b. Nurses held legally responsible for practicing within scope of practice

c. Specialty Organization: AWHONN -Association of Women’s Health, Obstetrics, and Neonatal Nurses d. Orientation Period/Specialization

-Labor and Delivery

-Nursery/Level II Nsy/NICU

-Postpartum/Mother-Baby-↑ since 1990’s -Occasional problems with

comprehensive care-territorial -Differences in opinions lead to pt confusion

II. Expanding roles in Perinatal Nurses a. Nurse Practitioners

-Defined by ANA as: provide

comprehensive health assessments, determine diagnoses

plan/prescribe treatment manage healthcare regimens for the individual, families, and the community

-In 1960’s, shortage of MD’s lead to 1

creation of the RNP

-May provide family care or specialize -Take part in a certificate program or Master’s Degree program

-Need at certification for third-party reimbursement

-Requires documentation of continued education and practice

b. Clinical Nurse Specialists

-Defined by ANA: Clinical expert who provides direct pt care services --health assessments

--health promotion

--preventative interventions -MSN

-Expertise in planning, supervising, and delivery of nursing care to families in childbearing period

-Case managers -Consultant

-Family and staff educator

-Coordination of delivery of nursing care to families requiring intensive nursing support

-Research activities/articles

-May work specifically with high risk pts -Traditionally worked in hospitals but now found in nursing homes, schools, home care settings and hospice.

c. Certified Nurse Midwife

-Defined by ACNM: independent management of women’s health care especially R/T pregnancy, childbirth, PP period, and care of the newborn

-Graduate from a certificate or MSN program

-Also provide family planning services, other gynecological needs, and peri/ postmenopausal care

-One of the oldest professions

-1925-Mary Breckenridge establishes 2

Frontier Nursing Services-first Nurse- Midwife to practice in the US

-American College of Nurse Midwives was incorporated in 1955

-provide care to women with low

incomes, uninsured, and minorities who don’t seek out regular health care -lower rates of cesarean sections in facilities where CNM’s practice d. Certified Nurse Anesthetists

-Defined by AANA: provide --pre-anesthetic assessment --develop and implement plan of care

--perform general, regional, local, and sedative anesthesia

--manage pt’s airway/pulmonary status

--facilitate emergence/recovery from anesthesia

--provide follow-up evaluation and care --respond to emergency situations

to asst with ACLS, airway, medications -Minimum 24 month programs/MSN with --45 hrs professional aspects --135 hrs anatomy/physiology/ pathophysiology --45 hrs chemistry --90 hrs anesthetic principles --45 hrs clinical/literature review

--knowledge of at least 450 anesthetics -80 % practice in an anesthesia care team -20 % practice independent at solo

providers

e. Nurse Consultants

-experts in a specific area of nursing -fee for service

-may act as expert witnesses

-used by corporations R/T developing products/equipment

-consult to texts, electronic media, and periodicals

B.

Legal and Ethical Issues

I. Litigious nature of this specialty

a. ↑ number of malpractice cases involving childbirth issues

-OB/Gyn cases 2nd _{only to surgeries} b. Minimum standard of care:

-care that a reasonable, prudent nurse would provide in the same or similar circumstances c. Predominant theory of Liability-negligence

-4 elements

duty exists

breech of duty-standard of care violated injury

connection between violation of the standard and the injury d. Malpractice lawsuits are based on the

assumption that the health care provider failed to meet the professional standard of care and resulted in injury

e. Alleged injury to fetus, neonate, or mother f. Families expecting a healthy child-bad

outcome means mistake must have been made

g. Attribute problem to one or more members of the health care team

-frequent unavailability of physician

-time frame to communicate may be short h. To support expert opinion, need evidence:

-hospital procedures -nursing policies

-guidelines established by professional organizations

-state nurse practice acts -JCAHO

II. Informed Consent

a. Process by which a pt decides to have a certain medical or surgical procedure -includes knowing and understanding what health care treatment is being undertaken

b. More than just signing a form

c. Process by which the physician, nurse, and possibly other health care professionals convey to pt the information for them to decide whether or not to proceed with the course of tx

d. Without proper consent, provider could be the subject of a lawsuit alleging assault, battery, negligence , or a combination of actions f. types of consent:

-expressed-oral or written

-implied: nurse states here to draw blood and the pt extends her arm

--may be used in emergency cases --when pt continues to take tx without objection

--during surgery, additional surgery is indicated

g. Informed refusal

-can take place at initiation of tx or any time after start of tx

-refusal is valid even after informed consent is given

-refusal must be voluntary, uncoerced, and not made under fraudulent circumstances -pt must refuse tx with knowledge and

understanding of the refusal

-chart should include signed refusal form by pt and nursing notes should include time left, left with whom, risks and

consequences of no further tx, and who will be notified

III. Common Legal Pitfalls

a. #1 allegation: birth of neurologically-impaired infant

b. reporting/recording errors: -incomplete initial H & P

-failure to observe & take appropriate action -failure to communicate changes in a pt’s condition in a timely manner

-incomplete and/or inadequate documentation -failure to use or interpret fetal monitoring

appropriately

-inappropriate pitocin monitoring/usage -improper sponge/instrument count c. almost ¾ of OB/Gyn’s have been sued

-most cases will not go trial but be settled out of court

d. 30% have had 3 or more law suits e. rising costs of liability insurance

f. ↑ demands for accountability created by expanding the scope of practices

g. cost containments -shorter hospital stays

-use of unlicensed asst personnel -decrease in hospital staff

h. changes in technology mean needed continued education: EFM

IV. Standards of Care

a. Standardized procedures/policies

b. supervision of unlicensed asst. personnel KNOW your facility’s Scope of Practice

VI. Ethical Dilemmas Unique to Perinatal Nursing a. fetal research-laws vary by state

b. fetal surgery

-i.e.: bilateral hydronephrosis, congenital diaphragmatic hernia

-what if mother refuses tx c. abortion-Roe vs. Wade (1973)

-morning-after pill

Plan B-levonorgestrel

-lack of estrogen ↓ nausea -medical abortion

US: mifepristone + misoprostol France: RU-486

d. artificial insemination

-AIH-husband’s sperm-problem with mother

-AID-donor sperm

-legal problems-donor relinquishes rights e. surrogate childbirth

-buying a child-$$$$

-biological mother may refuse to give up

the newborn

f. ART-Asst. Reproductive Technology -IVF-ET

-GIFT, ZIFT

g. embryonic stem cell research/cord blood banking

8 h. The Neonate

-iatrogenic procedures

prolonged use of ventilators

O2 therapy

-problem: should we save the lives of infants only to have them lead lives of pain, disability, and deprivation?

-who decides if major intervention is used -what kind of care do you give or deny the

infant to allow him to die with dignity and comfort

i. The Mother

-use life support in irreversible conditions? V. Nursing Role

a. Communication

-interactions between MD’s, CNM’s, & nurses

-was a clear line of communication used -was the chain of command followed -was there informed consent

-the better the communication between nurse and pt, less use of litigation -earlier discharges home mean more

educational responsibilities for the RN

b. Use of EFM

-first introduced at Yale University in 1958 -In last 25 yrs of use, no ↓ in rate of CP -is partially responsible for ↑ in C/S rate -ordinary part of Intrapartum care-

constant threat of legal action

C.

Review of Conception/Fetal Development

(Review books)

Uncomplicated Labor and Delivery

Lecture 2 (2 days)

I.

Physiological effects of the birth process

A.

Maternal response

1.

CV

a.

During U/C-300-500 ml blood from uterus

to vascular system

b.

Increase in cardiac output

10-15% Stage I

30-50% Stage II

c.

Blood pressure changes

1. blood

flow

↓ in the uterine artery

during contractions and is redirected

to the peripheral vessels

2.

peripheral resistance occurs with an

↑ in BP and ↓ of pulse

3.

Stage I- ↑ 30 mm Hg systolic

↑ 25 mm Hg diastolic

4. Stage

II-↑ BP further

5.

Supine hypotension-risk factors

multifetal, hydramnios, obesity,

dehydration,

hypovolemia

d.

WBC’s 25-30,000 mm secondary to stress,

trauma

e.

hematopoietic

1.

desire Hgb at least 11 g/dl

Hct 33% or higher

2.

↑ plasma fibrinogen→ ↓ blood coag

time→ ↑ clotting factors to protect

against hemorrhage but ↑ risk for

thrombophlebitis (inflammation of

vein in conjunction with formation

of

a

thrombus (blood clot of a vessel

2.

Fluids/electrolytes

a. Diaphoresis,

↑ insensible water loss through

respirations, NPO status, and ↑ temp

b.

Voiding may be difficult r/t anesthesia or

Pressure from presenting part-↓ sensation

of a full bladder

c.

Proteinuria-

-↑ in amino acids may exceed capacity

of renal tubules to absorb

-may be renal damage caused by

vasospasms of tubules

3.

GI

a.

Fluids at tolerated r/t ↓ GI motility and

absorption with delay in stomach

emptying

b.

N & V with diarrhea in labor

4. Respiratory

a.

↑ O

consumption, ↑ in resp. rate

b. hyperventilation

→respiratory alkalosis

↑ in pH, hypoxia, hypocapnia (↓CO

)

c.

2

_Stage-O

_{consumption ↑ → metabolic}

acidosis uncompensated by resp. alkalosis

5. Muscular/skeletal

a.

Fatigue of muscles/strain

b.

Separation of pubis symphysis

-May be related to pregnancy or

delivery process

(relaxin-polypeptide hormone-secreted

in corpus luteum during pregnancy-can

relax the symphysis, inhibit uterine

contractions, and softens the cervix)

c.

Breakdown of proteins may lead to

proteinuria-albumnin in the urine

6. Neurological

a.

Euphoria-believe it or not!

endorphins-↑ pain threshold and produce

sedation

b.

↑ anxiety

c.

partial to total amnesia in 2

_stage

7. Integumentary

a.

diaphoresis

b.

↑ temperature-may be R/T to maternal

efforts or infection

c.

exacerbation of pruritus-

may be related to cholestasis (arrest of

the flow of bile) in pregnancy

B.

Fetal Response

1.

CV

a.

∆ in fetal heart rate (FHR)

-maternal

hydration

N

&

V

↑ maternal temp

insensible

water

loss

-maternal

position

-medications

to

mother

-placental

issues

post dates-calcifications

smoker/↑ BP-↓ placental size

velamentous insertion (umbilical

cord attached to the

membrane a short distance

from the placenta

cord compresson

2. Pulmonary

a. thoracic

cavity

squeezed

-not as much in C/S cases

-precipitous deliveries (swift progression of

2

_{stage of labor marked by rapid}

descent/expulsion of the fetus)

-may

need

extra

suction

b. passing

of

meconium (1

feces of

neonate) may need resuscitation effort

3.

Catecholamines

a.

epinephrine & norepinephrine-active

amines (nitrogen-containing organic

compounds)

-have effect on CV, neuro, metabolic

rate, temp., and smooth muscle

b.

change R/T ↑ stress of labor

speed clearance of fluid

II. Essential

Components of the Birth Process

A.

Passageway

1.

maternal

pelvis

a.

4 bones

-2 innominate (nameless) bones

-made up of 3 bones

-ilium-iliac

crest

-ischium-ischial

tuberosity

-spines-shortest

diameter

-pubis-symphysis

pubis

-the sacrum

-the coccyx

b.

False pelvis-the upper pelvis

-portion above the inlet

c.

True pelvis

-inlet

-diagonal conjugate-lower border

of

symphysis

pubis-sacral

promontory

-usually 12.5 cm or greater

-obstetric conjugate- also called

anterior/posterior diameter

-measurement

that

determines

whether presenting part can

engage

superior

strait

-usually 1.5-2 cm less than

diagonal

-midpelvis-cavity, midplane

-transverse

diameter-interspinous

diameter-10.5 cm

-outlet

-transverse

diameter-intertuberous

diameter-> 8 cm

2. Pelvic

shapes

a.

gynecoid-round

-50% of women

-most favorable

-usual mode of birth-vaginal

b.

android-heart shaped

-23% of women

-usual mode of birth-cesarean

possible

forceps-difficult

c.

anthropoid-oval shaped

-24% of women

-usual mode of birth-vaginal

spontaneous or asst.

-may lead to OP position

d.

platypelloid-flat shaped

-3% of women

B.

Passenger

1.

Fetal skull

a.

made up of 6 bones

-frontal

-2 parietal

-2 temporal

-occipital

b.

not fused together-allow for molding,

overlapping of bones to pass thru pelvis

c.

sutures-membranes

-frontal

-sagittal

-lambdoidal

-coronal

d.

fontanels-where membranes intersect

-anterior (bregma)-diamond-shaped-2cm

by 3 cm

-closes by 18 months

-posterior-triangle-shaped-1cm by 2 cm

-closes by 8-12 weeks

e.

landmarks

-mentum-chin

-sinciput-brow

-vertex-between anterior/posterior

fontanel

-occiput-beneath the posterior fontanel

2. Fetal

Presentation

a.

fetal part entering the pelvis first

-cephalic (head)-96%

-breech (buttock)-3%

-transverse (shoulder)-1%

b.

factors that influence presentation

-fetal lie

-fetal attitude

c.

diagnosed using

-Leopold’s maneuvers

-verify with ultrasound

d.

external version-MD attempts to manually

rotate the fetus into a cephalic

presentation

-done in L &D

-ultrasound to check fetal/placental

position

-may use medications to relax uterine

muscle

-frequently uncomfortable for mother

3.

Fetal Lie

a.

relationship of long axis (spine) of fetus

to long axis (spine) of mother

b.

primary

lies:

-longitudinal

(vertical)-cephalic,

breech

-transverse (horizontal or oblique)-shoulder

4. Fetal

Attitude

a.

relationship of fetal parts to one another

b.

general flexion

-back is rounded

-chin flexed onto chest

-thighs flexed on the abdomen

-legs flexed at the knees

-arms crossed over the thorax

-umbilical cord lies between arms/legs

c.

head flexion

-biparietal diameter-9.25 cm

-suboccipitobregmatic-9.5 cm

-occipitofrontal-12 cm

5. Fetal position

a.

relationship of presenting fetal part to

4 quadrants of maternal pelvis

b.

indicated using a 3-letter abbreviation

-1

_{letter-location of part in pelvis (R or L)}

-2

_{letter-presenting part of fetus (O,S,M)}

-3

_{letter-location of presenting part in}

relationship to maternal pelvis (A,P,T)

6.

Station

a.

relationship of presenting fetal part to an

imaginary line at the maternal ischial

spines: 0 station is at the spines

b.

negative stations-higher in the pelvis

c.

positive stations-lower in the pelvis

C.

Powers

1.

Primary Powers

a.

involuntary uterine contractions

-start at fundus-thickened uterine

muscle layer of upper uterine

segment

-upper segment thicker so more active

-lower segment has less muscle

-contractions move down muscle

in waves

-assessed

by:

reports

from

mother

RN

palpating

fundus

monitor

b. primarily

responsible

for

dilation of

cx and descent of fetus

-drawing upward of the

musculofibrous components

of the cervix with fetal head compression

lead to dilation (opening)

the first stage of labor

c.

effacement (thinning)

-cx usually 3 cm long, 1 cm thick

-taken up by shortening of uterine

muscle bundles

-usually expressed in %

d.

uterine contractions

-3 phases-increment, acme, decrement

-involuntary, rhythmic, intermittent

-frequency-beginning of one to the

beginning of the next

-regularity-usually start irregular then

becomes more regular as labor

progresses

-duration-start

to

end

of

contraction

-intensity-mild,

moderate,

strong

or

strength

can

be

measured

with

internal

monitor

(IUPC)

with

resting tone usually 15-25 mm

e.

Ferguson’s reflex

-presenting fetal part reaches perineal

floor

-mechanical stretching of cervix occurs

-stretch receptors in vagina trigger

exogenous (originating outside an

organ) oxytocin release

-triggers maternal urge to bear down

2.

Secondary Powers

a.

bearing down effort at 10 cm

-contraction of diaphragm and

abdominal muscles while pushing

b.

↑ intraabdominal pressure that

compresses uterus on all sides

c.

usually no effect on dilation-important

R/T expulsion of fetus and placenta

to bear down rather than start pushing

at 10 cm

e.

debate over how to push

-valsalva-closed glottis, prolonged push

-open glottis pushing

-mini pushes

f.

prolonged pushing efforts can lead to

fetal hypoxia/acidosis and severe

maternal perineal lacerations

D.

Placenta

1. Structure

a.

formed at implantation

b.

decidua (endometrium during

pregnancy) basalis-with the chorion

(extraembryonic membrane) forms the

placenta

c.

cotyledon-mass of villi on the chorionic

surface of the placenta

-15-20 in number

d.

structure is completed by 12 week

e.

breaks may occur in placental

membrane allowing mixing of maternal

and fetal blood-Rh sensitization

f.

position problems

-previa-implanted in lower uterine

segment-covers internal cx os

-abruptio-separation of placenta from

uterine

wall

-accreta-cotyledons invaded uterine

musculature

-increta-invasion into the myometrium

-percreta-invasion to the serosa of the

peritoneum covering of the uterus

g.

umbilical cord insertion problems

-battledore-insertion into the margin of the

placenta-resembles a paddle

-velamentous-attached to membrane a

short distance to placenta

2. Function

a.

endocrine gland-produces hormones to

maintain pregnancy

-hCG-human chorionic gonadotropin

-basis

for

pregnancy

test

-preserves

function

of

corpus

luteum

-ensures continued supply of

estrogen/progesterone

-reaches max level at 50-70 days

-hPL-human placental lactogen

-similar to growth hormone

-stimulates

maternal

metabolism

-↑ resistance to insulin and facilitates

glucose transport across

placental membrane (GDM?)

-estrogen

(estriol)

-stimulates

uterine

growth

-stimulates

uteroplacental

blood

flow

-progesterone

-maintains endometrium

-decreases

contractility

of

uterus

-stimulates

development

of

breast

alveoli and maternal

metabolism

b.

metabolic functions

-respiration

-nutrition

-excretion

-storage

c.

factors which could effect function

-smoking

-drug use

-poor nutrition

-↑ BP

-maternal position

-infection

-trauma

E.

Psyche

1.

Factors influencing woman’s reaction to

physical/emotional crisis of labor

a.

accomplishment of tasks of pregnancy

b.

usual coping mechanisms in response to

stress

c.

support system-esp. partner’s

commitment

d.

preparation for childbirth

e.

cultural/religious influences

f.

social/economic responsibility

2.

Factors associated with birth experience

a.

motivation for pregnancy

b.

attendance at childbirth classes

c.

sense of competency/mastery

d.

self-confidence/self-esteem

e.

+ relationship with partner

f.

maintaining control during labor

g.

support during the delivery

h.

not being left alone

i.

trust in staff-medical and nursing

j.

pain management

k.

length of labor process-exhaustion, ↑

anxiety, ↑ for medical interventions

F.

Position (maternal)-See book

III. Labor

Physiology

A.

Labor Onset Theories

1.

Oxytocin

Stimulation

Theory

a.

stretching of cervical os causes ↑ in

exogenous oxytocin

b.

produced by posterior pituitary

c.

oxytocin stimulates smooth uterine muscle

contractions

d.

↑ response to oxytocin as nears term

2.

Estrogen Stimulation Theory

a.

estrogen stimulates smooth uterine muscle

to contract

b.

as approaches term, ↑ estrogen,

↓ progesterone (prog. keeps estrogen in

check)

c.

promotes prostaglandin synthesis (also

stimulates muscle)

3.

Progesterone Withdrawal Theory

a.

usually relaxes muscle

b.

at term-↓ in effectiveness

4.

Fetal Cortisol Theory

a.

at term, fetus produces more cortisol

b.

cortisol-(adrenocorticcal hormone)

-slows production of progesterone

-stimulates prostaglandin precursors

5.

Uterine Distention Theory

a.

stretching uterine muscles causes

irritability leading to contractions

6.

Prostaglandins

a.

stimulate smooth muscle to contract

b.

can have production stimulated by

various methods

-↑ synthesis of PGE

in amnion

c.

research varies whether concentration

of prostaglandins ↑ in amniotic fluid and

maternal blood just before labor onset

B.

Signs of Labor

1.

Braxton-Hicks

contractions

a.

4-6 weeks before onset of labor

b.

uterine muscle workout before labor

c.

may be strong and frequent but usually

are irregular in pattern

2. Lightening

a.

fetal descent into the true pelvis

b.

2-3 weeks in primigravidas

closer to onset of labor in multiparas

c.

easier to breathe, ↑ need to void

3.

Cervical and vaginal changes

a.

cervix ripens (softens) and may begin to

dilate and efface

b.

vaginal mucus ↑ with mucus plug being

released 1hr, 1day, or even 1 week before

start of labor

c.

occasionally bloody show noted with

dark brown or light pink-tinged mucus

noted

4.

Persistent low back ache

a.

R/T relaxation of pelvic joint and descent

of fetus

b.

change of position, warm packs, and

warm showers/baths help

5. Weight

Loss

a.

R/T GI upset with N & V and diarrhea

b.

usually starts 1-2 days before onset

6. Nesting

a.

have a burst of energy

b.

have a need to get everything in order

for arrival of baby

C. True vs. False Labor

True

False

Uterine contractions

regular

irregular

close

together

vary

stronger

milder

↑ with walking

↓ with walking

felt in low back then

felt in back or pelvis

radiates

to

abdomen

not stopped by bath

↓ with relaxation

or fluid

techniques

Cervix

softens, effaces, dilates

no significant changes

Fetus

starts descent into pelvis no change in position

D.

Effacement, dilation, and station

1.

Effacement

a.

thinning of cervix (shortening from usual

length of 2-3 cm)

2.

Dilatation

a. opening

of

cervical os from closed to

10

cm

b.

due to retraction of cervix into the lower

uterine segment R/T uterine contractions

and pressure from amniotic sac and fetus

c.

both dilation and effacement are

measured by fingertip palpation or visual

inspection with sterile speculum

3.

Station

a.

using imaginary line at ischial spines,

note location of presenting fetal part

b.

documented from –4 to +4

c.

ballottable-when presenting part is

floating in and out of the pelvis

E.

Stages and Phases of Labor

1.

Prodromal phase

a.

strong regular contractions without

cervical

change

b.

leads to exhaustion R/t inability to sleep

c.

may need oral/IM medication for rest

2.

Stage 1 (0-10 cm)-has 3 phases

a.

Early/Latent phase-0-3 cm, 50-90%, -3to -1

-able to walk and talk

-able to eat light meals

-may be home for most of this phase

-involves more cx effacement and less

change in fetal position

-U/C’s may be 2-10 minutes apart

-U/C’s

mild

by

palpation

-lasts an average 8 hours for primips

-multiparas may have cx dilate to 3 cm

-ROM may occur during this time

b.

Active phase-4cm-7cm, 80-100%, -2 to 0

-U/C’s every 3-5 minutes, moderate by

palpation

-U/C’s last approx 60 sec

-may start to have nausea/vomiting

-may ask for enema if impacted to

speed descent of fetus

-may ask for pain medications

-provider may decide to AROM to help

speed labor

-expect cx to change 1cm every 1-1.5 hrs

c.

Transition phase-8-10 cm, 100%, -1 to +1

-U/C’s every 1-3 minutes with ↑ intensity

-U/C’s last 45-90 sec long

-using breathing techniques not to push

too

early

-may ask for more pain medication

-shortest phase-usually 15 min-3 hours with

delays R/T medications/infections

3.

Stage 2-10 cm (pushing) to delivery of neonate

a.

nulliparas-2 hours on average-no epid.

3-4 hours with epidural

b.

multiparas-15 min-1 hour without epid.

1-2 hours with epidural

4.

Stage 3-birth of neonate to expulsion of

Placenta

a.

usually lasts 20 minutes to 1 hour

b.

if retained, MD will need to manually

remove-consider pain meds for mom

5.

Stage 4-Recovery

a. mom-1-4

hours

b.

baby-6 hours

F.

Mechanisms of Labor (Cardinal Movements)

1.

Engagement and Descent-occurs r/t:

a.

pressure of amniotic fluid

b.

uterine pressure on the breech

c.

contractions of abdominal muscles

d.

extension/straightening

of

fetus

2.

Flexion

a.

natural

attitude

of

fetus

b.

fetal head flexes as it meets

resistance

3. Internal

Rotation

a.

to go thru transverse diameter

b.

rotates

to

occiput

anterior

4.

Extension

a.

resistance of pelvic floor with vulva

opening

forward

and

anterior

b.

fetal head begins to crown

5.

External

Rotation

a.

shoulders rotate to anteroposterior

b.

fetal head rotates further to one side

6.

Expulsion

a.

anterior shoulder slips under

symphysis

pubis

b.

posterior shoulder and body is then

delivered

G. Labor Duration

1.

Nulliparas

a.

1

stage-13 hours (1.2 cm/hr)

b.

2

_{stage-5 minutes-2 hours}

c.

3

_{stage-10-20 minutes}

2. Primi/multiparas

a.

1

_{stage-7 hours (1.5 cm/hr)}

b.

2

_{stage-5 minutes to 1 hour}

c.

3

_{stage-5-20 minutes}

IV. Plan of Care

A.

Assessment-Data Collection

1. prenatal

record

a.

assess attendance to PN appts

b.

any complications of pregnancy

c.

any high risk behaviors

d.

abnormal lab/ultrasound reports

1.

blood type/RH factor

2. VDRL/RPR-syphilis

screen

3. HbsAG-surface

antigen

4. CBC

5. Rubella

immunity

6.

culture for GBS

7. urinalysis

8. HIV

test

e. primary

language

2. initial

interview

a.

ask why she came in

b.

status of BOW

c.

any U/C’s?

d.

any bleeding?

e.

+ FM recently?

3. physical

exam

a.

maternal vital signs

b.

FHR tracing

c.

palpate strength of U/C’s

d.

assess fetal presentation

e.

assess cervical dilation/effacement

4.

lab reports/ultrasound results

a.

CBC

b.

PIH panel

c.

RBS (sure step or lab draw)

d.

ck fetal lie/AFI with ultrasound

5. expressed

psychosocial and cultural

factors/needs

a.

history of sexual/physical abuse

b.

history of depression/suicide attempts

c.

social support

-family near by

-friends who can pitch in

d.

cultural/religious needs

6.

clinical evaluation of labor status

a.

sign consent forms

b.

CBC and urine test

c.

if ROM, ck nitrazine paper or ferning

d.

Leopold’s maneuver

e.

vaginal exam

f.

ultrasound if needed

g.

head to toe assessment

h.

ck for med allergies

i.

ask about classes taken

B.

Nursing Diagnoses

1.

Anxiety R/T labor and birthing process

a.

orient parents to unit

b.

explain admission protocol

c.

assess woman’s knowledge,

experiences, and expectations of

labor

d.

discuss progress of labor

e.

involve woman and partner in care

decisions during labor

2.

Pain R/T increasing frequency and intensity of

contractions

a.

assess level of pain

b.

encourage support people to aid in

comfort measures

c.

encourage use of relaxation techniques

d.

explain when and why analgesics may be

used

3.

Risk for altered pattern of urinary elimination R/T

sensory impairment secondary to labor

a.

palpate the bladder superior to symphysis

b.

encourage frequent voiding

c.

assist to BRP or use catheter prn

4.

Risk for fluid volume deficit R/T ↓ fluid intake

and blood loss during birth

a.

monitor fluid loss

b.

administer oral/parenteral fluid prn

c.

monitor fundus for firmness

d.

administer medications to aid in

contraction of uterus

e.

possible type and screen/cross match

if transfusion needed

5.

Impaired gas exchange R/T maternal ↓ BP,

compression of umbilical cord

a.

keep mother off her back

b.

maintain adequate hydration

c.

oxygen via mask if O

below 90%

d.

shut off pitocin

e.

possible need for amnioinfusion

C.

Interventions-Priority Setting

1.

Vital

signs

a.

notify provider if BP above 140/90

b.

ck temp q 4 hrs if ROM

2. Fetal

monitoring

a.

assess FHR at least once hourly in

early

phases

b.

may need continuous monitoring

c. consider

internal

monitoring for poor

tracing, lack of progress, or meconium

3. Hydration/oxygenation

a.

encourage po fluids or start IV if N & V

b.

ck oxygen saturation if decels noted

4. Comfort

measures

a.

breathing/focal points/distractions

-labor shakes are normal

b.

hydrotherapy/massage

c.

active listening R/T maternal behaviors

-0-3 cm: anticipation, excitement

-4-7 cm: seriousness, introspection

-8-10 cm: irritable, fatigue, amnesia

d.

use of support people

5. Pain

management

a.

showers/warm or cool packs

b.

massage

c.

oral medications

d.

IV or IM medications

e.

Epidurals

6. 2

_{stage interventions}

a.

room prepped for delivery

-warmer for neonate

-delee suction if meconium present

-possible need for Pedi

-keep up NRP/BLS skills

b.

asst mother with a variety of positions

while pushing

-short pushes 6-7 seconds

-consider open-glottis pushing

-squatting can open the pelvis an

addition ¼ inch

c.

assess need for addition oxygen R/T FHR

tracing

d.

assess maternal VS and FHR tracings per

hospital policies

e.

keep Provider aware of pt’s progress

f.

consider lessening epidural dose if

pushing effort less than adequate

g.

provider

should

be in LDR before head is

crowning to provide support for perineum

h.

clean perineum if requests by provider

i.

at delivery, asst partner with cutting of

7. 3

_{and 4}

_{stage interventions}

a.

asst provider with lidocaine/suture if

perineal/vaginal repair is needed

-episiotomies:

median or mediolateral

-lacerations:

1

_{degree-skin, superficial}

2

degree-muscles of perineum

3

_{degree-to anal sphincter muscle}

4

_{degree-anterior rectal wall}

b.

fundal rub post delivery of placenta

-watch for trickle/spurt of blood and

change

in

uterine

shape

to

herald

expulsion of placenta

c.

observe for need for pitocin/methergine

d. promote

bonding/breastfeeding

even

during repair

e.

ice pack to peri/VS q 15 min/pain meds

f.

prepare for possible trip to OR if placenta

is retained (↑ 1 hr)

g.

immediate newborn care

-dry off fluids, skin to skin, suction mucus

-ck for 3-vessel cord

-ck physical assessment/wt./length

-APGAR score and infant ID tags

V.

Electronic Fetal Monitoring-skills lab

VI. Related Pharmacology-medication administration cards

Analgesia and Anesthesia

Lecture 3

I. Labor

Pain

A.

Data Collection and Assessment

1.

Ask patient comfort level and current pain level

-0-10 scale or coping scale

-comfort level is when they can participate in

ADL’s without the need of pain meds

2.

Be aware of cultural differences in response to

pain

-Asian populations may not exhibit pain or ask

for pain medications

-Hispanic women may be very stoic until just

before the delivery of the baby

-Middle Eastern groups may be very vocal in

requesting early use of medications for pain

3.

Anxiety and fear of the unknown might

heighten their level of pain

4.

Previous experiences with childbirth or other

painful procedures may lead to higher levels of

concern about pain management needs

5.

Attendance to childbirth classes may aid in the

patient’s ability to cope through contractions

B.

First Stage

1.

Early phase-0-3 cm

a. nonpharmacological

methods

1.

focal

points

2.

massage/counterpressure

3. hydrotherapy/aromatherapy

4.

music

5.

breathing techniques

6.

Transcutaneous Electrical Nerve

Stimulation unit (TENS)

7.

heat/cold packs

8.

hypnosis

b. pain

medications

1.

should be discouraged as they

could slow the labor process

2.

usually orals:

percocet

vicodin/norco

benadryl

acetaminophen

3.

occasionally IM:

morphine with phenergan

2.

Active phase-4-7 cm

a.

may use many of the same

non-medication choices as above

b.

when pain is more intense, usually

requests IV medications for fast

action

-fentanyl

-nubain

-stadol

c.

may also request and receive an epidural

at this stage in labor

3.

Transitional phase-8-10 cm

a.

may request epidural

b.

may want to be out of bed and push on

toilet to relieve backache

c.

encourage position changes if possible

d.

short acting IV narcotics still ok but have

Narcan available for infant resuscitation

C.

Second Stage

1.

May continue pushing with epidural pump on if

efforts are affective

2.

May receive local anesthesia for repair of

perineal laceration or episiotomy

3.

If no epidural is in place, may receive a

pudendal block which relieve pain in the

vagina, vulva, and perineal regions

D.

Third Stage

1.

If placenta is retained, may receive IV pain

medications or be moved to OR for twilight

sleep

2.

For laceration/episiotomy repairs, use of local

anesthetics or pudendal block (less common)

II.

Adverse Effects of Excessive Pain

A.

Physiological effects

1.

Effect on cervical change-more in pain, less

able to relax and let the labor progress

2.

Tensing up against the pain leads to muscle

and ligament strains in other parts of the body

3.

May not keep properly hydrated and nourished

R/T the intensity of the pain

4.

Inability to relax back muscles and do deep

breathing may lead to difficulty placing

epidural catheter

B.

Psychological effects

1.

“I can’t do it”-ineffective pushing due to fear

of pain

2.

inability to make decisions R/T pain

3.

may become hostile to staff/family R/T

inability to cope

III. Factors Influencing Perception of Discomfort

A.

Teens and Older Primigravidas

B.

Cultures/Religions

C.

Previous experiences with pain

D.

Support person

E.

Preparatory classes

IV. Pertinent Nursing Diagnoses

A.

Pain R/T physiologic response to labor

1.

assess patient’s knowledge of labor and

relaxation techniques

2.

encourage support people to aid in comfort

measures

3.

teach alternative non-pharmacological

methods of pain relief

4.

assess need to void/defecate

5.

encouraging resting between U/C’s

6.

keep pt. and family notified of labor progress

7.

offer possible choices for pain medications if

all other methods have been unsuccessful

B.

Other possible nursing diagnoses

1.

Ineffective airway

2.

Fluid volume deficit

3.

Fetal oxygenation

4.

Anxiety R/T pain

5.

etc. (see others in book)

V. Pharmacological

Pain

Management

A.

Considerations for the Pregnant Patient

1.

What medications you give the mom you give

the fetus

2.

Maternal concerns that she wasn’t

“strong enough” to make it thru without

pain meds

3.

Need to taper dosage to the patient

4.

If previous abuser of medications, will pain med

even be effective

B.

Analgesics, sedatives, and adjuncts

1.

Sedatives may be given in early labor to aid

With sleep and anxiety but can lead to a

Slowing of the labor progress and noted

respiratory depression in the patient along with

vasomotor depression of both mom and fetus.

2.

Analgesics

a.

can be systemic crossing the blood/brain

barrier as well as the placental barrier

b.

IV is preferred over IM due to rapid onset

but IM medications last longer

c.

narcotic compounds

-Demerol-meperidine

-Sublimaze-fentanyl

-Stadol-butorphanol

-Nubain-nalbuphine

-respiratory depression

-tachy/bradycardia

d.

analgesic potentiators

-usually antiemetics (Phenergan, Vistaril)

-decrease anxiety and apprehension

-helps reduce the amount of narcotic

needed

for

relief

C. Anesthetics (Regional and General)

1.

Local block

a.

usually used on perineal region

b.

1% lidocaine used

c.

injected into skin and subcutaneous

d.

epinephrine may be added to intensify

anesthetic and decrease bleeding

2.

Pudendal block

a. goal

to

anesthetize the pudendal nerve

located near the ischial spines

b.

may decrease ability to bear down R/T

lack of sensation

extraction of placenta or uterine

exploration

3.

Epidural block/PCEA

a.

needs IV bolus before insertion R/T

maternal hypotension due to

vasodilation

b.

done by CRNA or MD

c.

pt. awake for procedure/delivery

d.

pt. sitting up for placement

e.

after insertion, may need frequent

position changes side to side to

keep anesthetic level equal

f.

preferred block T10-S1

g.

need Foley cath in bladder due to

inability to feel when to void

h.

possibility of spinal headache if needle

placement is not correct

i.

saturates pain receptors but not motor

one

j.

may need to use Ephedrine

(a vasopressor) if maternal BP ↓

k.

usually a local anesthetic alone or

mixed with a narcotic (fentanyl, etc.)

l.

may increase labor time and need for

pitocin augmentation

m. antiemetics, antipruritics, and narcotic

antagonists should be handy to treat

possible side effects of epidural

n.

as with any medication, be prepared for

possible severe adverse reactions such

as bronchospasms, sudden ↓ in BP,

dyspnea, or convulsions-crash cart should

be available on unit

4.

Spinal block

a.

local anesthetic into the L

, L

, or L

interspace→subarachnoid space

b. medication

mixes

with CSF-saturates

pain and motor receptors

c.

used for cesarean sections

d.

risk of spinal headache due to leak

of CSF-may need to remain supine post

delivery, IV maintained, and possible

blood patch

e.

IV bolus given prior to procedure R/T

risk of maternal hypotension, ↓ CO,

and placental perfusion

e.

maternal BP, pulse, resp. effort, and FHR

are assessed every 5 minutes for the first

15-30 post injection

5.

General anesthesia

a.

while rarely used, may be needed for C/S

if unable to access regional block or in

emergency

cases

b.

NPO, IV, oral sodium citrate before start

c.

RN may be asked to give cricoid pressure

to

aid

anesthesiologist

in

tube

placement

d.

normally recovered in PACU (recovery rm)

so bonding with infant delayed

e.

higher

risk

of

complications vs. regional

blocks-mother

unconscious

during

birth

of infant

f.

as with all anesthesias used during C/S,

wedge should be placed under mom’s

R hip to displace uterus to the L

g.

besides C/S, general anesthesia may be

needed

during

manual

placenta

removal

or D & C

Nursing in the Normal Puerperium (the period of 42 days post childbirth and expulsion of the placenta)

Lecture 4 I. Physiology of the puerperium

A. Alterations in the body systems as a result of the birth process 1. Reproductive system

a. involution of uterus-return to non-pregnant state-caused by contractions of uterine muscles (size of a grapefruit after 3rd _stage) b. within 12 hours, fundus at U/U

c. fundus descends 1-2 cm/24 hrs

d. uterus not palpable after the 9th _{PP day} e. ↓ in estrogen/progesterone=autolysis f. subinvolution-failure of uterus to return to

non-pregnant state-usually involves retained POC or infection

g. outer decidua sloughs off as lochia, inner layer becomes new endometrium

h. oxytocin released from pituitary gland helps uterus to contract-↑ with BF

i. afterbirth pains ↑ in multiparas

j. placental site regeneration complete at 6 wks k. change in lochia-rubra-1-3 days-bright red

serosa-3-10 days-pink, brown alba-10 dys-2 wks-yellow, white l. cervix-bruised, soft, swollen-closes by 2 wks

-external os-appears as jagged slit

m. vagina-returns to prepregnancy state by 6-8 wks n. perineum-healing start by 2-3 wks, complete

within 4-6 months -Red -Edema -Ecchymosis -Drainage -Approximation

o. 6 months for return of pelvic musculature 2. Cardiovascular

a. CO remains elevated for 2 weeks-12 wks before ↓ to prepregnancy values

b. EBL 300-500 ml-vaginal birth 500-1000ml –C/S

c. blood volume increased by:

-elimination of uteroplacental circulation -loss of placental endocrine function which

removes stimulus for vasodilatation -mobilization of extravascular water stored d. Vital signs:

-Temp-↑ to 380 _C/₁₀₀4 _{F R/T dehydration} -Pulse-↑ 1st _{hr-return to pre-preg. 8-10 wks} -Resp-↓ by 8-10 wks

-BP-may have orthostatic hypotension e. Hgb/Hct:

-1st _{72 hrs-↑ loss of plasma volume compared to} RBC’s

-↑ in H & H by day 7

f. WBC’s may ↑ to 25-30,000/mm3

g. Coag factors-hypercoagulable state may lead to possible thromboembolism

3. Gastrointestinal a. ↑ appetite

b. no BM for 2-4 days post delivery -encourage ambulation -hydration

-fiber

-medications, i.e.: stool softeners c. tx hemorrhoids-ice packs, tucks, crm

-no pr meds if 3rd_-4th _{degree laceration} d. Kegel exercises to strengthen pelvic floor 4. Renal

a. returns to normal function 1 month after birth -bladder tone returned by 5-7 days

b. diuresis-from fluid retention, pitocin, etc c. excessive vaginal bleeding may be noted if

bladder is allowed to get distended with urine 5. Musculoskeletal

a. joints stabilize 6-8 weeks post birth

b. may have permanent increase in shoe size c. may have separation of symphysis pubis or

6. Integumentary

a. chloasma (mask of pregnancy) usually fades by end of pregnancy

b. hyperpigmentation of areolae and linea nigra may continue

c. may note perfuse diaphoresis post delivery 7. Endocrine

a. Expulsion of placenta=↓ in estrogen, cortisol progesterone, and hPL (hCS)

[human placental lactogen/human chorionic somatomammotropin]

-reverse diabetogenic effect-lower BS level b. if BF-↑ prolactin levels for 6 weeks

if bottle-fed-↓

-usually means later ovulation in lactating women

8. Psychosocial

a. parent’s acceptance of infant’s needs and abilities

b. need to learn cues, understand emotional states

c. bonding-proximity, touch, voice, interaction d. identify infant as an individual yet part of the

whole family

e. mutuality-infant’s behaviors stimulate mom’s f. may feel attracted to alert, responsive infant and repelled by irritable, disinterested infant g. attachment occurs more readily with the

infant whose temperament, social capabilities, appearance, and sex fit parent’s expectations h. need to assess mother-infant communication i. behaviors

-entrainment-moving in time with adult speech -biorhythmicity-soothed by mom’s heartbeat -reciprocity-responds to cues

-synchrony-mutually rewarding

j. maternal adjustments

-taking in-first 24 hrs-focus on self and basic need Dependent, passive

-taking hold-last 10 days to several weeks-focus on care of baby and competent

mothering-dependent

-letting go-focus on forward movement of the family unit

k. PP blues- 70% of women-mood swings, anger, depression, letdown, fatigue, insomnia, H/A’s, weepiness (resolves in 10-14 days) l. PP depression-7-30%-more severe syndrome

-depression, feeling of failure overwhelming guilt, loneliness

II. Nursing Process

A. Data collection/Assessment 1. Vital signs

2. Fundus

a. ck fundal location, tone, lochia b. have pt empty bladder before exam 3. Bladder

a. assess for distention

b. measure first voids until 500 ml (voided out) c. catheterize if needed

4. Perineum

a. if repair done, assess site for intactness, edema, hematomas, redness, or drainage (REEDA) b. assess for presence of hemorrhoids

5. Breasts

a. note if breast are filling-palpate

b. note any redness, soreness, cracking of nipples

B. Nursing Diagnoses

1. Risk for fluid volume deficit 2. Alteration in urinary elimination 3. Pain

4. Fatigue

5. Ineffective breast feeding 6. Situational low self-esteem

7. Anxiety due to lack of knowledge base 8. etc.

C. Interventions 1. Safety

a. infant ID bands b. orientation to unit c. staff picture ID’s d. move infant in crib 2. Standard precautions

a. wash hands before handling baby b. change linens

c. proper hygiene

d. use of squeeze bottle for peri care e. wiping front to back

f. teach pt about fundal massage

g. use of peppermint or running water to aid in voiding to prevent urinary retention

h. use of ice packs for the first 12 hours post repair of peri then instruct on use of sitz bath i. squeeze buttocks together when sitting or rising

from a chair to help keep repair intact j. wear good supportive bra

k. use lanolin crm to prevent cracking of nipples l. warm packs before breast feeding, cool packs

post

m. walk as soon as possible-helps with gas pains n. take pain meds prn

o. encourage rubella vaccine if non-immune pt should prevent getting pregnant for at least 4 weeks post vaccination

p. Tdap-Pertussis-

q. rhogam given to Rh – moms who had Rh+ babies III. Early Discharge

A. Candidates and criteria

1. Newborns’ and Mothers’ Health Protection Act of 1996 a. 48 hours minimum post vaginal delivery

b. 96 hours minimum post C/S

c. pt and doctor may agree on earlier D/C 2. Maternal criteria for early D/C

a. VSS b. voiding c. Hgb >10 d. no bleeding

3. Infant criteria for early D/C a. term infant

b. VSS

c. normal physical assessment d. at least 2 successful feedings e. at least 1 void and 1 defecation f. no jaundice

g. circ site ok

h. newborn blood/hearing screenings done i. follow-up in 1 week

j. maternal/infant teaching cklist completed IV. Care of the Cesarean Birth Patient

A. Assessment/Interventions

1. VS every 15 min X 1hour, 30 min X 1 hour, then per

hospital protocol

2. monitor I & O’s-need UO at least 30 ml/hr 3. assess abdominal dressing for drainage 4. assess need for pain medication

5. assess fundal location, tone, and lochia (still have 3 distinct lochia stages) 6. ambulate asap

7. assess for passage of gas-advance diet as tolerated 8. C & DB-may use inspirometer

B. Nursing diagnoses 1. Fluid volume deficit 2. Pain

3. Risk for infection 4. Risk for injury

5. Anxiety R/T surgery, fetal well-being 6. Situational low self-esteem

C. Possible post-op complications 1. CV-hemorrhage, shock, dvt 2. Pulm-embolus, pnemothorax 3. GI-paralytic ileus

4. GU-renal failure, hematuria, UTI, oliguria 5. Reprod-endometritis, emboli

V. Care of the Lactating Woman A. Physiology of Lactation

1. Female breast has 15-20 lobes containing alveoli (the milk producing cells)

2. alveoli→ductules→lactiferous ducts→nipple

3. ↓ estrogen & progesterone post delivery=↑ prolactin levels which remain above baseline thru duration of lactation (highest level is at day 10)

4. Prolactin:

-highest level at day 10

-is produced in response to infant’s sucking

-promotes milk production by stimulating alveolar cells B. Other hormone changes/reflexes

1. Oxytocin responsible for let-down reflex

nipple stimulation→pituitary produces oxytocin→ makes cells around the alveoli contract→sends milk to nipple

2. Nipple erection reflex

infant cries or rubs against the breast→nipple becomes erect→propulsion of milk

C. Supply/demand

1. First milk called colostrum a. rich in immunoglobins

b. higher concentration of protein and minerals to mature milk but less fat

c. promotes growth of Lactobacillus bifides in GI 2. If infant is well nourished, will see 6-8 wet diapers and

3 stools in 24 hours at day 5 of breastfeeding 3. Incomplete emptying can lead to ↓ milk supply 4. watch for infant growth spurts

-10 days -3 weeks -6 weeks -3 months -4.5-6 months D. Maternal nutrition/considerations

1. add addition 200-500 calories/dy while breastfeeding 2. drink 2-3 liters of fluid daily