Labor & Delivery

Labor & Delivery

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OB Pharmacology

  • Tocolytics
    • Slow contractions
      • Terbutaline
      • Magnesium-sulfate
  • Oxytotics
    • Stimulate contractions
      • Oxytocin

Terbutaline

  • Therapeutic class: Selective Beta 2 adrenergic agonist.
  • Mechanism of action: Binds to beta 2 adrenergic receptors in the respiratory system to cause bronchodilation by inhibiting the release of hypersensitivity reaction products from mast cells. ALSO works on beta 2 receptors in the uterus to slow or stop contractions.
  • OB Indications
    • Preterm labor
  • Nursing considerations
    • SE: shakiness, jitteriness, dizziness, drowsiness, sleep disturbances, weakness, headache, nausea, vomiting tachycardia, hypertension, hyperglycemia. CNS overstimulation.
    • Assess HR, BP, EKG, blood glucose
    • Monitor HR of mom and baby when used in labor. Monitor fetal heart monitor strips closely.
    • Monitor EKG

Magnesium-sulfate

  • Therapeutic class: Electrolyte
  • Indication: Hypomagnesemia, torsade de point, pre-eclampsia, preterm labor, seizures, asthma exacerbation
  • Nursing Considerations:
    • Monitor for hypermagnesemia
      • Confusion, dizziness, weakness, decreased reflexes
    • Give IV slowly

Oxytocin

  • Therapeutic class: Hormones
  • Indication: Induction of labor; PPH
  • Action: Stimulates uterine smooth muscle causing it to contract
  • Nursing Considerations:
  • Monitor contractions
  • Monitor fetus
    • Warn mother contractions will be more painful
    • Monitor BP, HR, glucose, and K

Stages of labor

  • 1
    • Latent
      • 0-3 cm cervical dilation / Contractions 5-30min apart.
    • Active
      • 4-7 cm cervical dilation / Contractions 3-5 mins apart.
    • Transition
      • 8-10 cm cervical dilation / Contractions 2-3 mins apart.
  • 2
    • Delivery of Baby
      • 10 cm (complete) cervical dilation to birth
  • 3
    • Delivery of Placenta
      • Birth of baby to expulsion of placenta
  • 4
    • Postpartum
      • 1-4 hours after birth, maternal physiologic readjustment

The end of the first stage of labor (8-10 cm dilation) is commonly referred to as the “transition phase” of labor.  This period is often characterized by perineal/rectal pressure due to fetal descent, which the client may perceive as an urge to have a bowel movement.  The maternal ischial spines are designated as the “0 station” landmark.  During this period, descent of fetal station below the maternal ischial spines (ie, +1 station or greater) often results in nausea and vomiting and trembling or shivering 

Fetal presentation

Fetal presentation (eg, cephalic, breech) and position (ie, location of the fetal presenting part in relation to the maternal pelvis) are essential components of a labor assessment.  The position of the fetus in the maternal pelvis can greatly affect duration of labor and location of pain during uterine contractions.  A right or left occiput anterior position is the optimal fetal position for a vaginal birth.

Complications

Placenta Previa

  • Assessment
    • Major symptom is PAINLESS bright red bleeding
    • The fact that it is painless is very important
    • That sets it apart from an abruption
    • To assess the bleeding
      • Pad count to determine the amount
      • Clots
      • Color
    • Ultrasound done to confirm diagnosis
    • Ultrasound will determine type of previa

  • Nursing Interventions
    • Never ever perform a cervical exam if you suspect a placenta previa!
    • Would never want to irritate the placenta or uterus.
    • Continue to monitor for blood loss.
      • Client may have to stay on the unit to be monitored
      • Preform pad counts
      • Weigh pads
        • 1 gram = 1 mL blood loss.
    • Bed rest
      • This may minimize blood loss
    • Monitor baby
      • If there is excessive blood loss, perfusion to the fetus can be decreased.
    • Cesarean section indicated in most cases

Abruptio Placentae

  • Types
    • Causes massive amounts of painful bleeding.
      • Two types
        • Incomplete
        • Complete
    • Incomplete is only partial separation of the placenta.
      • Causes internal bleeding
      • Blood backs up behind the placenta
    • Complete is when the placenta completely detaches
      • Causes massive external bleeding
      • Very painful

  • Assessment
    • Dark red bleeding
    • Intense abdominal pain
    • Board like abdomen (due to internal bleeding)
    • Rigid uterus
    • Hypotension (Think shock due to blood loss)
    • Maternal tachycardia
    • Fetal bradycardia (fetal distress!!)

  • Interventions
    • Monitor for fetal distress
      • Signs of distress? Stat c-section!
    • Monitor maternal bleeding
      • Abdominal pain
      • Board like abdomen
      • Dark red vaginal bleeding
      • Change in fundal height (blood in abdomen?)
    • Keep the BP up with IVF and/or blood products
    • Prepare for delivery – most likely c-section.

Prolapsed Umbilical Cord

What is a prolapsed cord?

Umbilical cord slips through the cervix and into the vagina after rupture of membranes and before the baby descends into the birth canal. During delivery, the prolapsed cord become compressed by the presenting part of the fetus. This cuts off oxygen to the fetus.

  • Assessment
    • Cord visualized protruding through vagina
    • Cervical exam
      • Something squishy?
      • Pulsing?
      • Mom feels something between legs

  • Nursing Interventions
    • Elevate the presenting part of the fetus off of the prolapsed cord
    • Keep your hand on the baby’s head lifting it up and call for help
    • Positioning
      • Knees-to-chest position – open the pelvis
      • Trendelenburg – let gravity shift the baby off the cord
    • Administer oxygen
    • Wrap cord in sterile moist towel

NEVER ATTEMPT TO PUSH THE CORD BACK IN!

Emergency Cesarean delivery

Postpartum Hemorrhage

Risk factors for PPH

  • Twins or triplets
  • Macrosomic fetus
  • Preeclampsia
  • Prolonged labor
  • Precipitous labor
  • Use of forceps or vacuum during delivery
  • Placenta previa
  • Abruptio placenta

Assessment

  • Boggy uterus
    • This is a uterus that is not contracting to clamp down on the blood vessels
    • The fundus will feel soft instead of hard as it should.
  • Blood loss
    • Pad counts – most PPH clients are saturating pads every 15 minutes
    • Puddle of blood in the bed
    • If they try to stand up for the first time there could be a huge gush of blood
  • Shock – if there is large amounts of blood loss leading to hypovolemia
    • Decreased LOC
    • Pale
    • Diaphoretic
    • Hypotensive
    • Tachycardic

Interventions

  • Fundal massage
    • Massage the fundus – hard!
    • Warn the mother this will hurt, but you must do it to get the uterus to contract and stop the bleeding.
    • Every 15 minutes at a minimum
  • Estimated Blood Loss (EBL)
    • Weigh pads to estimate the loss
    • 1 g = 1 mL
    • Monitor hemoglobin and hematocrit
  • Mediations
    • Oxytocin
    • Methylergonovine
    • Blood products