NURS 3550 / NURS3550 3.1 Module Introduction The nurse plays an important role in caring for the pregnant client and her family during the birth process.
... [Show More] Women who have a positive birthing experience are more likely to return to the health care facility for other health issues than those women who do not have a positive birthing experience. It is important for the nurse to understand what is involved in the care of the laboring and birthing client. The process of labor and birth, fetal assessment during labor, pain management during labor and birth, complications that may occur during labor, birth procedures, and the nursing implications are discussed. Processes and Stages of Labor and Birth, Intrapartal Nursing Assessment There are special issues facing nurses caring for childbearing families during the intrapartum period. Nurses may be faced with feelings of inadequacy at times, especially male nurses or female nurses who have never given birth. Nurses also may have to face their own positive or negative experiences with childbirth. The progress of labor is an unpredictable process, with no clear answers for the laboring mother and partner. Caring for the laboring client and partner takes patience and high technological skills. The labor nurse must be proficient in the associated technology along with providing necessary pain relief. Intimacy may also be an issue. Labor and birth is a very intimate process for the mother and her family. Sometimes nurses find it difficult to provide care without feeling as if they are being intrusive. Labor and delivery nurses must be familiar with the “5 Ps”: the processes that affect the labor process. This lesson will cover these issues as well as the nursing assessments required when caring for a client transitioning through the labor and birthing process. The “5 Ps” of Labor: Primary and Secondary Powers Click on the picture to enlarge. The first “P” is the “power” of the uterine muscle and the establishment of a satisfactory contraction pattern (primary powers), which takes place primarily during the first stage of labor, and the maternal pushing efforts (secondary powers), which takes place during the second stage of labor. The contracting uterus during labor has two opposing features. The upper two thirds of the uterus actively contracts to push the fetus down and out. The lower one third of the uterus and the cervix remain less active, promoting the downward movement of the fetus. Because the upper portion of the uterus becomes thicker, the lower segment becomes thinner and is pulled upward, resulting in what is known as a “physiological retraction ring.” This retraction ring helps to maintain fetal descent and cervical change. The uterine contraction cycle consists of three phases: • The increment, or the ascent, of the contraction starts in the fundus, spreading through the uterus to the cervix. • The peak, or acme, of the contraction is its most intense point. • The decrement is the “letting up” or decline of the contraction. • The interval is the period of uterine relaxation between contractions. When describing uterine contraction activity, nurses are assessing contraction frequency, duration, and intensity. • Contraction frequency refers to the time in minutes between the start of one contraction and the start of the next contraction. • Contraction duration refers to the time in seconds between the start of one contraction and the end of the same contraction. • Contraction intensity refers to the strength of each contraction during the acme. Contraction intensity cannot be accurately measured with external fetal monitoring and must be palpated by the nurse. The nurse places his or her hand on the uterine fundus to judge the indentability of the abdomen wall. If indentation is easily accomplished, the contraction is considered mild, or +1. If the abdomen wall cannot be indented, the contraction is considered strong, or +3. Indentation that falls in between is considered moderate, or +2. The purpose of uterine contractions is to dilate and efface the cervix to facilitate the birthing process. • Dilation of the cervix refers to the widening of the cervical opening, orcervical os, as the result of pressure from the fetal presenting part during contractions. Cervical dilation is measured in centimeters, on a scale of 0–10, with 10 cm being full dilation. • Cervical effacement refers to the shortening or thinning of the cervix during labor. Normally, the cervix is long and thick, approximately 2–3 cm in length. The force of the uterine contractions causes the muscle fibers of the cervix to thin and shorten. Effacement is measured by percentage on a scale of 0–100%, with 100% being fully effaced. The secondary power occurs during the second stage of labor with maternal bearing down efforts during a contraction. Maternal bearing down efforts should begin after the cervix is completely dilated. Pushing before that time can cause cervical swelling, bruising, and possible lacerations, which will prolong the cervical dilation. The “5 Ps” of Labor: The “Passenger” The third “P” is the fetus. The fetus is the “passenger” and plays an active part in the labor process as it moves and turns to accommodate itself to the maternal pelvis. The fetus enters the pelvis in thecephalic presentation approximately 96% of the time. The five bones, four sutures, and two fontanelles of the fetal head make it possible for the fetus to adapt to the maternal pelvis and birth canal. The bones of the fetal head consist of two fontal bones, two parietal bones (crown), and one occipital bone (back of the head). The sutures are made of a flexible fibrous tissue and consist of the following: • Frontal suture, which separates the two frontal bones • Coronal suture, which separates the frontal from the parietal bones on each side • Sagittal suture, which separates the two parietal bones • Lambdoid suture, which separates the occipital bone from the parietal bones on both sides The two fontanelles are formed at the intersections of the sutures and bones of the fetal head. The anterior fontanelle is diamond shaped and is formed by the intersection of the frontal, coronal, and sagittal sutures. The posterior fontanelle is smaller, is triangular shaped, and is formed by the intersection of the lambdoid and sagittal sutures. The diameters of the fetal skull also influence the fetus’s ability to navigate the maternal pelvis and birth canal. The diameters consist of the suboccipitobregmatic, the biparital, the occipitomental, and the occipitofrontal. The fetal lie refers to the orientation of the long axis of the fetus to the long axis of the mother. In a longitudinal lie, the fetus’s long axis is parallel to the mother’s. With a transverse lie, the fetus’s long axis is at right angles to the mother’s. An oblique lie refers to the fetus’s long axis being at some angle between a longitudinal and transverse lie. Fetal attitude refers to the relation of the fetal body parts to each other. A normal fetal attitude is one of flexion with the fetal head flexed toward the chest, the arms and legs flexed across the thorax, and the back in a “C” shape. Fetal presentation refers to the fetal part that enters the pelvis first. The most common presentation is the cephalic; however, the presentation can be breech or shoulder. The cephalic and breech presentations have several subcategories. Fetal position describes the location of a fixed reference point on the presenting part with the four quadrants of the maternal pelvis—right or left anterior and right or left posterior. The position is not fixed but changes as the fetus makes its descent. The “5 Ps” of Labor: The “Passenger” The third “P” is the fetus. The fetus is the “passenger” and plays an active part in the labor process as it moves and turns to accommodate itself to the maternal pelvis. The fetus enters the pelvis in the cephalic presentation approximately 96% of the time. The five bones, four sutures, and two fontanelles of the fetal head make it possible for the fetus to adapt to the maternal pelvis and birth canal. The bones of the fetal head consist of two fontal bones, two parietal bones (crown), and one occipital bone (back of the head). The sutures are made of a flexible fibrous tissue and consist of the following: Frontal suture, which separates the two frontal bones Coronal suture, which separates the frontal from the parietal bones on each side Sagittal suture, which separates the two parietal bones Lambdoid suture, which separates the occipital bone from the parietal bones on both sides The two fontanelles are formed at the intersections of the sutures and bones of the fetal head. The anterior fontanelle is diamond shaped and is formed by the intersection of the frontal, coronal, and sagittal sutures. The posterior fontanelle is smaller, is triangular shaped, and is formed by the intersection of the lambdoid and sagittal sutures. The diameters of the fetal skull also influence the fetus’s ability to navigate the maternal pelvis and birth canal. The diameters consist of the suboccipitobregmatic, the biparital, the occipitomental, and the occipitofrontal. The fetal lie refers to the orientation of the long axis of the fetus to the long axis of the mother. In a longitudinal lie, the fetus’s long axis is parallel to the mother’s. With a transverse lie, the fetus’s long axis is at right angles to the mother’s. An oblique lie refers to the fetus’s long axis being at some angle between a longitudinal and transverse lie. Fetal attitude refers to the relation of the fetal body parts to each other. A normal fetal attitude is one of flexion with the fetal head flexed toward the chest, the arms and legs flexed across the thorax, and the back in a “C” shape. Fetal presentation refers to the fetal part that enters the pelvis first. The most common presentation is the cephalic; however, the presentation can be breech or shoulder. The cephalic and breech presentations have several subcategories. Fetal position describes the location of a fixed reference point on the presenting part with the four quadrants of the maternal pelvis—right or left anterior and right or left posterior. The position is not fixed but changes as the fetus makes its descent. The “5 Ps” of Labor: The “Maternal Psyche” The fifth “P” is the woman’s psyche or emotional state. The woman’s psyche or emotional state can determine her total response to labor and influences her physiological and psychological functioning. Influencing factors include the mother’s previous birth experiences (Were there any complications? What were the outcomes? Were the mother’s personal expectations met?). At the same time, the mother’s current pregnancy experience will influence her response to the pregnancy. Her age, marital status, current number of children she has, as well as her current expectations for this pregnancy are all influencing factors. Cultural values are another influencing factor. A woman’s culture gives her clues about how she should act or respond during pregnancy, labor, and delivery. Her values and beliefs regarding sickness, health, and pregnancy will shape her definition of what the childbirth experience should be. Other cultural factors that can affect a mother’s behavior during childbirth include expectations about who should attend the birth, the mother’s perception of and response to pain (should pain be expressed openly or should she be stoic), and the woman’s feelings about being touched. When facing labor, whether for the first time or fifth time, women may have feelings of anxiety or fear about the process. The feelings of fear may center on anticipating the pain associated with labor or the fear of losing control and not being able to cope. Nurses can help by providing guidance regarding strategies the laboring woman can use to cope with the stress and discomforts of labor. Processes of Labor: Theories of Labor Onset The actual cause of labor onset is unknown; however, there are several theories. The consensus is that it is a combination of things that cause labor to begin. The estrogen/progesterone theory suggests that increased estrogen levels allow the myometrium to become more sensitive to oxytocin, and decreased progesterone levels increase myometrial contractility. Research also shows an association between prostaglandinproducing agents stored in the fetal membranes and the onset of labor. The fetal endocrine theory suggests that as the fetus matures, the adrenal glands secrete corticosteroids that trigger mechanisms leading to labor. The nurse needs to be familiar with the theories behind the onset of labor and must be able to discern the difference between true and false labor. BraxtonHicks contractions, or false labor, are characterized by irregular contractions that may or may not be painful. Position change or activity can often lessen contraction discomfort. False labor does not cause cervical change. True labor is characterized by a regular contraction pattern that becomes increasingly more intense. It is felt primarily in the lower back, sweeping around the sides to the lower abdomen. With true labor, activity does not decrease the frequency of the contractions pattern. Cervical dilation and effacement will occur if the woman is in true labor. It is not uncommon for women to feel discouraged when they come to the hospital thinking they are in labor and then find out that they are not. Nurses can provide these women with reassurance as well as education regarding the signs of true labor. Processes of Labor: Premonitory Signs of Labor Premonitory signs of labor are those signs that labor is imminent. [Show Less]