Labor & Delivery Nursing

Ana H. Corona, MSN, FNP-C Nursing Instructor October 2007

More presentations @: www.nurseana.com
Chilbirths.com; Medical Nursing Review 2007

Physical Examination of the Laboring Woman

Steps you should take to prepare for the examination: Ask woman to empty bladder (collect urine for testing). Prepare to follow a logical order. Prepare to chart logically immediately after exam (make notes). Remember to use all your senses during assessment Remember to explain everything you are doing. Exam should be carried out immediately and as quickly as possible.

Urine tests used during intrapartum

Ph: Measures acidity/alkalinity of the urine.below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration. Protein: Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH. Glucose Normal = Negative or + I. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high. Ketones Normal = Negative. Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus.

Perform Physical Exam

General appearance: Edema, skin color, hygiene, pain, distress, mood Measure vital signs: Blood pressure, pulse, respiration, temperature Blood pressure Take blood pressure with woman in sitting or side lying position Compare blood pressure with prenatal blood pressure At what point would you determine if the patient were hypertensive? What additional assessments and interventions would you take if patient were hypertensive? Test for proteinuria. Assess for facial and general edema. Test for hyperreflexia. Ask if patient is having headaches, blurred vision, spots in vision. Notify provider of any pathologic results

Physical Exam
Pulse Rate: 60 - 90 Increased pulse can be dehydration, anxiety. Always question possibility of cardiac problems. What is the most common cardiac problem in a young female? Respiration Dont count during a contraction Temperature Think about infection and dehydration

Abdominal Exam An abdominal examination should include a measurement of fundal height as well as an assessment of fetal size (estimated fetal weight), Presentation and position using Leopold's maneuvers. Inspect: Scars, linea, striae, symmetry Palpate: fundal height, fetal position Auscultate: fetal heart tones Determine and palpate contractions Inspect and palpate lower extremities Press firmly with thumbs about 5 seconds over shin If any signs of elevated blood pressure, elicit DTR If reflexes are hyperactive, check for clonus

Measuring Fundal Height

Place the zero line of the tape measure on the anterior border of the symphysis pubis and stretch tape over midline of abdomen to top of fundus. The tape should be brought over the curve of the fundus. The height of the fundus in centimeters equals the number of weeks gestation plus or minus 2. After 32 weeks the relationship is less accurate.

Leopolds Maneuver
Abdominal Examination for Position and Presentation and Size

Are used to determine the orientation of the fetus through abdominal palpation. Hands have an acute sense of touch especially when attached to a well-trained mind. You should always assess for position, presentation, engagement and size by abdominal examination. With warm hands and gentle pressure palpate the abdomen for soft consistency, fluctuating amniotic fluid, indefinite outlines and babys small knobby parts.

Monitoring the Mother and Fetus During Labor A 20 minute fetal monitor strip is done for all patients on admission. As long as the patient is healthy, the presentation normal, the presenting part well engaged, and the fetus in good condition, the woman may walk about or be in bed as she wishes. The patient's condition and progress is checked periodically. FHT's are checked q 30 min in latent phase, q 15min. in active phase, and q 5min. in second stage. The maternal temp is taken q 4 hrs., q 2 hours if ROM. Variations to this timing depend on the maternal-fetal situation.

labor
The progress of labor is followed by abdominal or vaginal examination to note the position of the baby, the station of the presenting part, and the dilatation of the cervix. These examinations should be done only often enough to ensure the safe conduct of labor, i.e., to determine that the rate of dilatation is within the normal range or to evaluate the patient if she is requesting medication.

labor
Over distension of the bladder is obviated by urging the patient to void every few hours. If she is not able to do so, catheterization may be necessary, since a full bladder impedes progress. Adequate amounts of fluids and nourishment are essential. If the patient is unable to take enough orally, a intravenous of Lactated Ringers solution may be given.

Labor
During the first stage, the patient should be impressed with the important of relaxing with the contractions. Help the couple as much as possible to work with the contractions and compliment them for a good job. The passage of meconium stained fluid in a cephalic presentation is a possible sign of fetal distress and if present, the patient should be continually monitored during active labor.

Abdominal examination for contractions

An initial abdominal examination is carried out on admission by laying a hand on the uterus and palpating, noting the degree of hardness during a contraction and timing its length. This should be repeated at intervals throughout labor in order to assess the length, strength and frequency of contractions and the descent of the presenting part. The uterus should always feel softer between contractions.

The monitor should never be relied on; the mothers abdomen should be regularly palpated by hand

Abdominal exam for contractions

Uterine contractility can be quantified subjectively by palpation or objectively by the use of an external tocodynamometer or an intrauterine pressure catheter (IUPC). The external tocodynamometer can generally provide reliable information about the frequency of uterine contractions and their approximate duration

Uterine contractions
The actual amount of intrauterine pressure generated with each contraction must be measured by internal devices, such as the intrauterine pressure catheter. The traditionally used measure of uterine work is called the Montevideo method. Montevideo units are calculated by totaling the peak uterine pressures (in mm/Hg) minus the baseline pressures over a ten minute period. At least 200 Montevideo units are required before the forces of labor can be considered adequate (i.e., when a protraction or arrest disorder is noted measures should be taken to ensure that contractions at least 200 Montevideo units exist before a cesarean delivery is undertaken).

Uterine Contractions

Fetal heart checks

A fetal heart check and an abdominal palpation for fetal position and presentation should always precede initial vaginal examination. The vulva should be carefully inspected for lesions (e.g., herpes, etc), some assessment of the superpubic angle, prominence of the iliac spine and size of the pelvis in relation to the fetal head should be made. Purpose of exam is to assess the status of membranes, fetal presentation and position, engagement, effacement, cervical dilatation and station.

Status of Membrane
Lie and Presentation Engagement

Status of membrane
Effacement Station

Procedure
Prepare client the same way as for a speculum examination. Lubricate index and middle finger of examining hand generously. Separate the labia with gloved fingers. Inspect vaginal opening (introitus). Observe for: Amount of bloody show: advanced labor Ruptured membranes Discharge that is malodorous Discharge that is deep yellow or greenish brown: Meconium Ulcerated areas on perineum: Herpes, Syphilis

Examinations
Examinations are done with aseptic technique (sterile gloves and antiseptic solution). You insert two fingers into the vagina and feel the cervix and the top of the babys head to gather information about the dilation and the presentation of the baby. This may be uncomfortable, especially during a contraction.
Cervical dilation: 1 finger represents aprox 1.5 cm

Vaginal Exams
There is no place for routine vaginal examinations in any labor. Vaginal examination should only be done when there is doubt about the clinical situation or symptoms, and the information gathered is necessary or likely to be of use in making a clinical decision. Excessive vaginal examinations carry with it the risk of increased infection. You should rely on behavior and emotional responses and physical sensations rather than vaginal exams.

Reasons to defer or avoid digital vaginal examination

The vaginal examination should be avoided or deferred in certain circumstances. In most of these situations a careful speculum examination is acceptable: (1) Significant vaginal bleeding of unknown etiology (delay examination until placenta previa has been ruled out by ultrasonography), (2) Presence of placenta previa, (3) Ruptured membranes in patients who are not in labor and for whom immediate induction of labor is not anticipated, (4) Presence of active HSV lesions in a patient with ruptured membranes.

Questions to ask yourself as you perform a Vaginal Examination

Status of amniotic membranes: Are they intact. Bulging through the cervix? Status of cervix: Is it soft or firm (the cervix must be soft before it can efface and dilate), anterior or posterior? (the cervix must be anterior before it can really start to dilate) How much effacement? 0%/long and thin to 100%/completely thinned out. How much dilation? 0 (closed) to 10 cm. (dilation complete).

Questions: continued
Fetal presentation: What is the presenting part? (head, breech, other fetal part) What is the fetal position? (left/right, anterior/posterior/transverse) Fetal station: What is the presenting part in relation to the ischial spines? Engagement: Is the presenting part engaged and well applied to the cervix? stabilized in the middle of the pelvis below the level of the ischial spine [zero station].

Assessing Cervical effacement Cervical effacement: Palpate degree of thickness; normal cervix about 1 inch thick

How to determine station Station is the relationship of the presenting part to the ischial spines. Locate the lowest portion of presenting part, then sweep the fingers deeply to one side of pelvis to feel for ischial spines. To determine station estimate in centimeters, the tip of presenting part is above the ischial spine. Tell the mother your findings.
Levels of progress through the pelvis using 5 to +5

Mechanism of labor
The following definitions must be mastered to be able to discuss and understand the mechanism of labor: Attitude. This refers to the posturing of the joints and relation of fetal parts to one another. The normal fetal attitude when labor begins is with all joints in flexion.

Mechanism of Labor
Lie. This refers to the longitudinal axis of the fetus in relation to the mother's longitudinal axis; i.e., transverse, oblique, or longitudinal (parallel). Presentation. This describes that part on the fetus lying over the inlet of the pelvis or at the cervical os. Point of Reference or Direction. This is an arbitrary point on the presenting part used to orient it to the maternal pelvis [usually occiput, mentum (chin) or sacrum].

Mechanism of labor
Position. This describes the relation of the point of reference to one of the eight octanes of the pelvic inlet (e.g., LOT: the occiput is transverse and to the left). Engagement. This occurs when the biparietal diameter is at or below the inlet of the true pelvis. Station. This references the presenting part to the level of the ischial spines measured in plus or minus centimeters.

Normal mechanisms of labor/Cardinal Movements - Occiput anterior positions Definition: A mechanism of labor is a series of passive, adaptive movements of the fetal head and shoulders through the birth canal. Related factors
Passage: Size and morphology of the pelvis Passenger: Size of the baby and moldability of the fetal skull Powers: Quality (efficiency) of uterine contractions and voluntary expulsive forces and quality and direction of soft tissue resistance, especially of the levator ani muscles Psyche: Moms attitude

Cardinal movements of labor

1. Engagement: Mechanism by which the greatest transverse diameter of the head in vertex (biparietal diameter) passes through the pelvic inlet (usually 0 station). The head usually enters the pelvis in the transverse or oblique - the inlet is a transverse oval.

Cardinal movements of labor

2. Descent: This occurs intermittently with contractions and is brought about by one or more forces: Pressure of the amniotic fluid, direct pressure of the fundus upon the breech, contractions of abdominal muscles (2nd stage) and extension and straightening of the fetal body.

Cardinal movements of labor

3. Flexion: As soon as the vertex meets resistance from the cervix, walls of the pelvis or the pelvic floor, flexion results. The chin is brought into contact with the fetal thorax and the resenting diameter is changed from occipitofrontal to suboccipitobregmatic (9.5 cms.)

Cardinal movements of labor

4. Internal Rotation: After engagement, as the head descends, the lowermost portion of the head (usually the occiput) meets resistance from one side or the other of the pelvic floor and is rotated about 45 degrees anteriorly to the midline under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet.

Cardinal movements of labor

5. Extension: With further descent and full flexion of the head, the nucha (the base of the occiput) becomes impinged under the symphysis. Upward resistance from the pelvic floor causes the head to extend, with the bregma, brow, nose, mouth and chin being born successively.

6. Restitution
When the head is free of resistance, it untwists, causing the occiput to move about 45 degrees back to its original left or right position. The sagittal suture has now resumed its normal right angeled relationship to the transverse (bisacromial) diameter of the shoulders.

7. External Rotation
The shoulders have entered the pelvis and engaged with the bisacromial diameter in the transverse or in an oblique diameter. The leading (anterior) shoulder meets the resistance of the side of the pelvic floor and is rotated anteriorly toward the midline under the symphysis. This movement brings the long axis of the shoulders in line with the long axis of the pelvic outlet. The movement of the shoulders causes the occiput to rotate another 45 degrees, to the transverse position.

8. Expulsion: Delivery of the anterior shoulder, posterior shoulder, and the rest of the body

The 6 steps of labor progression

Labor can be defined as regular, painful uterine contractions that result in progressive cervical change. The diagnosis of labor progression may be dependent upon the patient's history of uterine contractions as well as information gathered from abdominal palpation and vaginal examination. Evidence of progressive cervical effacement and/or dilation is necessary in order to distinguish true labor from false labor.

NOTE:
Labor progresses in six ways and all are equally important. Frequency, duration and intensity of contractions cannot be relied upon as measures of progression in labor. Cervical dilatation and fetal descent are the only indicators that labor is progressing.

1. Cervical Ripening
The cervix ripens or softens. As a womans body gets ready to labor it produces prostaglandin. This causes the cervix to soften from the consistency of rubber to something that feels like a marshmallow.

2. Cervical Position
The cervix moves from a posterior to an anterior position. During most of the pregnancy, the cervix points toward the back (posterior), but during the last few weeks of pregnancy or in early labor, it moves forward (anterior). The uterus may contract for several days intermittently before true labor begins to accomplish these first two things, softening the cervix and bringing the cervix from the back of the vagina to the front of the vagina.

3. Cervical Effacement
The cervix effaces About two inches in length is average size, but in early labor, the cervix begins to get shorter and thinner (effacement). By the active part of labor the cervix will be completely effaced and be paper-thin. It is vital to understand that when the cervix has not undergone the first three steps (ripening, effacement, and anterior movement of the cervix), significant dilation (beyond 3-4 cm in the nullipara, more in the multipara) rarely occurs), but that pre-labor contractions are accomplishing the important job of pre-paring the cervix to dilate.

4. Cervical Dilatation
The cervix dilates and active labor begins. Not much dilatation can occur until the cervix has completed the above three processes. Remember the cervix needs to get very soft, move to an anterior position and get paper-thin before it will dilate much past 34 centimeters.

5. Fetal Head rotation, flexion and molding

The head begins to change shape to fit through the pelvis. Remember, this is called molding. Rotation, flexion, molding, and descent of the fetal head take place in active labor and second stage

6. Fetal Descent and Birth

The fetus descends and is born. Descent occurs as the baby lowers itself into your pelvis. Remember, descent is measured in terms of "stations."

Stages of Labor
The first stage of labor begins when uterine contractions of sufficient frequency, intensity and duration result in effacement and dilation of the cervix. The first stage is completed when the cervix reaches 10 cm. The second stage involves descent of the fetus and its eventual expulsion from the vagina. It begins with complete cervical dilation (10 cm) and ends with delivery of the infant. The third stage of labor involves delivery of the placenta. It begins with the completion of the infants' delivery and ends with delivery of the placenta and membranes.

1st Stage of Labor

FIRST STAGE LABOR LATENT Pre-labor

Ripening and effacement of the cervix

LATENT-EARLY LABOR (0-3 cm.)

Contractions: 5-20 minutes apart 30-45 seconds long Mild, feel like cramps, back pain, pressure

ACTIVE LABOR (4-8 cm.)

Contractions: 2-5 minutes apart 45-60 seconds long Stronger and more intense

TRANSITION LABOR (8-10 cm)

Contractions: 1 -2 minutes apart 45-90 seconds long The strongest they will get

SECOND STAGE LABOR (10 cm. -Birth)

Contractions: 3-5 minutes apart 60-120 seconds long Less aware of contractions, more aware of urge to push and fullness in vagina as baby moves down

THIRD STAGE Delivery of the Placenta

Contractions: Irregular A feeling of fullness and cramping as placenta separates A time for mom to hold and enjoy baby.

Prolonged Latent Phase A prolonged latent phase is present when the active phase of labor is not achieved after 14 hours in multiparous patients and 20 hours in nulliparous patients. There are two basic methods for prolonged latent phase, narcotic analgesia or oxytocin augmentation of labor.

Prolonged or Protracted Active Phase

A protracted active phase is defined as progression at less than 1.2 cm an hour in nulliparous patients and less than 1.5 cm and hour in parous patients during the active phase. This disorder is associated with a higher incidence of occiput posterior and occiput transverse fetal positions. It may also be indicative of true cephalopelvic disproportion or it may result from inhibitory effects of narcotics analgesia. Condition is treated by first assessing the adequacy of labor (i.e., placing an intrauterine pressure catheter and determining the number of Montevideo units).

Prolonged or Protracted Active Phase The size of the fetus in relation to the pelvis must also be determined. The 3 Ps when addressing active phase labor abnormalities: The power refers to the adequacy of labor The passenger refers to the size and attitude of the fetus The pelvis refers to the size and shape of the maternal boney pelvis. In these cases labor augmentation with oxytocin is indicated if uterine contractile forces are found to be inadequate.

Active Phase Arrest This is the most common abnormality of labor in women who are ultimately delivered by cesarean section. It is defined as a lack of cervical progress over 2 or more hours, despite adequate uterine contractions (> 200 Montevideo units). As with Protracted Active Phase, the three P's must be assessed and in most cases a trial of oxytocin augmentation given.

Second Stage Disorders:

The average primigravida can expect to spend one to two hours in the second stage of labor while the multiparous women will typically have a second stage of 30 minutes duration or less. These times may be significantly increased in patients who have epidural anesthesia. In the presence of an epidural anesthetic the second stage may last as long as three hours in a nulliparous patient and as long as 1-1/2 hours in a parous patient.

Protracted Descent: Common causes of protracted descent include poor maternal expulsive effort and excessive fetal size relative to the maternal pelvis. A common management approach to protracted descent is to simply allow a longer period of time for the patient to push. In a patient with epidural anesthesia who has poor effort initially, expectant management can be undertaken while the patient is allowed to relax for the first 1 to 1-1/2 hours after becoming completely dilated (laboring down). When the fetal vertex reaches a +2 station or more a forceps or vacuum delivery may be used.

Arrested Descent
Arrested Descent occurs when there is no advancement of the presenting part for more than an hour. The criteria are the same in both the nulliparous and multiparous patients. The reasons for this disorder are the same as Protracted Descent. Reducing the level of maternal epidural anesthesia may be helpful in some cases. Additionally, changes in maternal position such as having the mother assume the "squatting" position may be helpful.

Fluids
IV fluids (usually dextrose and water or lactated Ringer's solution) are indicated when the mother is NPO status and should be run at a rate of 125 mL per hour, which ensures that the mother receives 1,000 mL of fluid every 8 hours. A normal healthy woman, who already has approximately 2 L of stored body water in extravascular spaces. Routine IV fluid administration can induce fluid overload, hyperglycemia in the fetus, and hypoglycemia in the newborn, and can alter plasma sodium levels.

Comfort Measures for the Laboring Woman

Do not leave alone in active labor. Change soiled and damp linen promptly. Provide mouth care. Ice chips, lubricate lips. Keep room cool, uncluttered, quiet and privacy. Promote participation of coach. The use of a specific breathing pattern during labor contractions has two objectives: Helping the woman relax by distracting her from the intense contraction sensations. Ensuring a steady, adequate intake of oxygen

Breathing techniques This technique is done only during contractions. Rest and sleep between contractions is important. Instruct the laboring woman to do the following: Assume a comfortable position. Try to maintain a relaxed state throughout the contraction. Close her eyes or concentrate on a focal point while doing the breathing (e.g., a pretty picture, a button on someone's shirt). Cleansing Breath Begin and end each breathing technique with a cleansing breath. This is simply a deep quick breath, like a big sigh. Inhalation is through the nose; exhalation is through slightly pursed lips.

Slow paced breathing

This technique can be used in early labor and for as long as the mother is comfortable with it. For some women, this may last throughout the entire first stage of labor. 1. Take a cleansing breath as soon the contraction begins. 2. Breathe slowly and deeply in through the nose and out through slightly pursed lips or the nose over the duration of the contraction. 3. Maintain a steady rate of approximately 6 to 9 breaths during a 60-second contraction (the cleansing breaths do not count).

Anesthesia
Neuraxial and regional techniques, with minimal motor blockade are now popular. Neuraxial analgesia is defined as intrathecal or epidural administration of opioids and/or local anesthetics for treatment of postoperative pain or other acute pain problems. Neuraxial analgesia includes epidural, spinal and combined spinalepidural techniques.

Procedure Description
Patients receive a 1 liter LR IV bolus and an oral antacid (Bicitra) prior to the placement of the epidural. The fluid bolus potentially alleviates any precipitous drops in the patients blood pressure. B/P are recorded prior to the start of the epidural, when a test dose is administered, when a bolus dose is administered, and q 5-15 minutes until stable. After one hour of stable BP's, BP's can be recorded q 30 min until delivery. FHR and contractions are recorded at these intervals also. Patients are kept NPO or ice chips only after placement.

Anesthesia
1st stage of labor, anesthetic dosages are given to limit the block to the (T10) and upper lumbar. This allows perineal tone to be maintained to avoid interfering with internal rotation of the fetal hd to the occiput anterior position. 2nd Stage of labor, the block can be extended to the sacral area to promote perineal relaxation, delivery, and episiotomy repair. Pt-controlled epidural anesthesia: allows the pt to self-titrate periodic amounts of anesthetic

Nursing personnel should understand

The risk of respiratory depression, including delayed respiratory depression when hydrophilic opioids are used Assessment and management of respiratory depression Assessment of motor and sensory blockade Assessment and management of hypotension in patients receiving neuraxial analgesia Signs and symptoms of the rare, but catastrophic, complications of neuraxial analgesia.

Intrauterine Resuscitation
What is intrauterine resuscitation? Interventions undertaken to attempt to change the relationship of the uterus, placenta, cord, and fetus to improve placental and fetal oxygenation. These are empirically designed to overcome uteroplacental insufficiency or to decrease cord compromise.

These include the following Positioning the mother to right/left side lying recumbent or knee-chest to improve blood flow to the uterus Repositioning the mother to alleviate cord compression Discontinuing oxytocin -Tocolysis with subcutaneous Terbutaline to decrease/moderate uterine activity and improve blood flow Increasing IV fluids to enhance maternal blood flow volume Administering oxygen to the mother in an effort to promote oxygen flow across the placental membrane

Amniotomy
Artificial rupture of membranes performed at or beyond 3 cm dilation. The technique involves perforation of the fetal membranes with a sterile plastic instrument (amnihook) or by applying a fetal scalp electrode through the membranes onto the fetal scalp. The procedure may be associated with changes in the fetal heart rate (e.g., accelerations or bradycardia) secondary to prolonged uterine contraction, secondary to release of a large quantity of fluid or in some cases prolapse of the umbilical cord.