OB - Week 6

• Nonpharmacological pain relief interventions during labor:

  • Emotional support
  • Physical support
  • Informational support
  • Advocacy
  • Support of the partner and family
• Emotional support:

  • Sustaining physical presence, eye contact
  • Verbal encouragement, reassurance, praise
  • Listening
  • Guided imagery, relaxation, distraction, and focal points
• Physical support:

  • Relaxation and breathing techniques
  • Massage and effleurage
  • Acupuncture or acupressure
  • Counter pressure
  • Transcutaneous electrical nerve stimulation (TENS)
  • Hydrotherapy
• Informational support:

  • Provide information on the progress of labor
  • Explain all procedures
  • Use interpreters if needed
• Advocacy:

  • Support decisions made by the woman and family
  • Ensure respect for women's decisions
  • Manage the environment, including visitors
  • Translate the women’s wishes to others
• Support of the partner and family:

  • Offer support and praise
  • Role model therapeutic behaviors
  • Assist the partner with food and rest
  • Provide breaks
• Pharmacological pain relief interventions during labor:

  • Nurses have a responsibility to present accurate, non judgmental, accessible information, then support the woman in the choices she has made, in collaboration with the provider
  • General anesthesia
  • Systemic analgesics
  • Local anesthesia
  • Regional anesthesia
• General anesthesia:

  •  LAST RESORT
  • affects your consciousness (out cold)
  • emergency situations!
  • risks to MOM and BABY → very high
• Systemic analgesics:

  •  Parenteral opioids → butorphanol (Stadol), Nalbuphine (Nubain), Sublimaze (Fentanyl), Morphine
  • usually IV 
  • Maternal SE → N/V, sedation, pruritus (itching), respiratory depression
  • Neonate → crosses the placenta (babies can feel the effects as well), can cause decreased FHR, respiratory depression→  lower apgar scores
  • Inhaled Nitrous Oxide
  • Self administered to reduce anxiety and increase a feeling of well being 
  • quick actions 
  • “laughing gas”
  • Do not affect muscles in lower extremities
• Local anesthesia:

  • prevent pain in a small area of the body
  • commonly used for tissue repair (episiotomy or perineum area)
  • Nursing care → monitor for return of sensation, swelling at injection site
  • Adverse effects → risk of hematoma and infection
• Regional anesthesia: blocks nerves in a specific area of the body, such as the arm or leg

  • Epidural, spinal, or pudendal block
  • Epidural = most common form of pain relief
  • Before procedure: verify consent; assess baseline BP, HR, RR, temp, pain; TIME OUT -> make sure everything is obtained, and verify it is the right pt; Labs-> Plt, type and screen; IV fluid bolus (NS or LR); ensure emergency equipment is available
  • During: Assist with positioning -> lateral position with head flexed to chest, elbows on knees, feet supported; breathing/relaxation; monitor MOM and BABY
• Before regional anesthesia:

  • Before procedure: verify consent; assess baseline BP, HR, RR, temp, pain; TIME OUT -> make sure everything is obtained, and verify it is the right pt; Labs-> Plt, type and screen; IV fluid bolus (NS or LR); ensure emergency equipment is available
• During Regional anesthesia procedure:

  • Assist with positioning -> lateral position with head flexed to chest, elbows on knees, feet supported; breathing/relaxation; monitor MOM and BABY
• After regional anesthesia procedure:

  • assess for HYPOtension, resp. distress, sedation; assess FHR Q5-15 min; assess for effective pain relief
  • SE: pruritus, N/V, headache, urinary retention
• Nursing care with anesthesia:

  • assess fetal status and maternal baseline blood pressure, pulse, RR, temp, O2 status, and labor progress before the administration of regional analgesia or anesthesia
  • administer an IV fluid bolus as a preload
  • Conduct a time-out before the administration of regional analgesia or anesthesia
  • initiate pharmacological hypotension prophylaxis
  • Assess for severe adverse maternal reactions during and immediately after the administration
  • Assess uterine activity and FHR patterns every 5 min for the first 15 min after the initiation
• Baseline FHR: FHR rounded to increments of 5 bpm during a 10 min window

  • Periodic → changes in baseline of FHR occur in relation to UCs
  • Episodic → changes in baseline of FHR occur independent of UCs
  • Recurrent→  changes in baseline of FHR occur in greater than or equal to 50% of the contractions in a 20 min period
  • Intermittent →  changes in baseline of FHR in less than 50% of the contractions in a 20 min period
• Baseline Variability: fluctuations in the baseline FHR that are irregular in amplitude and frequency. The fluctuations are visually quantified as the amplitude of the peak to trough in bpm. it is determined in a 10- min window, excluding accelerations and decelerations. It reflects the interaction between the fetal sympathetic SNS and parasympathetic nervous system
• Baseline variability:

  • Absent → amplitude range is undetectable
  • Minimal → amplitude range is visually detectable at 5 bpm or less
  • Moderate → amplitude from peak to trough is 6 bpm to 25 bpm
  • Marked → amplitude range greater than 25 bpm
• Accelerations: visually apparent, abrupt increase in FHR above the baseline. The peak of the acceleration is 15 bpm or greater over the baseline FHR for 15 or more seconds and less than 2 min
• Decelerations: Transitory decrease in the FHR from the baseline

  • Early deceleration
  • Variable deceleration
  • Later deceleration
  • Prolonged deceleration
• Early deceleration:  is a visually apparent gradual decrease in FHR from baseline to nadir (lowest point of the deceleration) taking more than 30 secs. The nadir occurs at the same time as the peak of the UC. Onset, nadir, and recovery match the onset, peak , and end of the UC. It’s always periodic.
• Variable deceleration: is a visually apparent abrupt decrease in the FHR from baseline to nadir taking less than 30 secs. The decrease in FHR is greater or equal to 15 bpm and less than 2 min in duration. It can be periodic or intermittent
• Late deceleration: is a visually apparent gradual decrease of FHR from baseline to nadir taking more than 30 secs. Nadir occurs at the peak of the UC. Onset, nadir, and recovery occur after the respective onset, peak, and end of the UC. It is always periodic
• Prolonged deceleration:  is a visually apparent abrupt or gradual decrease in FHR below baseline that is 15 bpm or greater lasting 2 min or more but 10 min or less. It can be periodic or intermittent
• Tachycardia: baseline FHR of greater than 160 bpm lasting 10 min or longer

  • Maternal causes: fever, infection/chorio, dehydration, anxiety, anemia, medication, substance abuse (cocaine)
  • Fetal causes: Infection/sepsis, activity or stimulation, chronic hypoxemia, cardiac abnormalities, anemia
• Bradycardia: baseline FHR of less than 110 bpm lasting for 10 min or longer

  • Maternal causes: supine position, dehydration, hypotension, cardiopulmonary compromise (cardiac arrest, seizures), medications (anesthetics), uterine rupture, placental abruption
  • Fetal causes: umbilical cord occlusion, hypoxemia, hypothermia, hypokalemia, fetal head compression
• Normal FHR: Category 1 reflects absence of metabolic acidemia at the time the EFM pattern is observed, and reflects favorable physiological response to maternal-fetal environment 

  • 110-160 bpm
  • regular rhythm
  • presence of FHR increases from baseline and absence of FHR decreases
• Contractions “normal” or expected findings

  • frequency: 5 or less contractions in 10 min
  • Duration: less than 90 secs
  • Intensity Rating: Mild, moderate, strong (SUBJECTIVE); mmHg with IUPC
  • Resting tone: between UCs → soft- palpation/or 7-25mmHg - IUPC, maintained for a minimum of 30 secs
• Gate control Theory of pain: An alternative activity can replace travel of the pain impulses to the brain
• FHR - Fetal heart rate

  • Monitoring: tool to assess fetal oxygen
  • we are looking at FHR and its response
  • the goal → maximize fetal oxygenation, maximize uterine and umbilical blood flow, maintain appropriate uterine activity, and support maternal coping and labor progression
• Influences on FHR:

  Extrinsic →

  • uteroplacental Unit

  Intrinsic influences →

  • autonomic nervous system
  • baroreceptors → arches of heart
  • CNS
  • chemoreceptors → responses to not having good bicarb or oxygenation
  • hormonal regulation→ cortisol
• Fetal reserves: describes the reserve oxygen available to the fetus to withstand the transient changes in blood flow and oxygen during labor

  • depleted reserves- fetus may not be able to adapt to or tolerate decreased oxygen that occurs during labor/UCs
  • interpretation of FHR data allows us to predict fetal response to labor
• Acid base analysis:  tool to assess fetal acid base balance at birth  and help evaluate whether a poor neonatal outcome is due to a hypoxic event before or during labor
• Assessing Labor Pain:

  • Labor pain is non pathological and is associated with bringing new life into the world 

  1. asking the open-ended questions, “how are you coping with labor?”
  2. Assessing for signs that the woman is coping → outward signs of pain
• Coping signs related to pain during labor: willing to push, vitals would look good, breathing well and through contractions, moving and swaying/changing positions to get comfy
• Non coping signs related to pain in labor: crying, screaming, yelling, sweating, trembling, shaking, and fainting, grimacing on face, muscle tenseness (not relaxed), not breathing (holding breath)
• 3-Tier FHR system:

  • Category 1 = indicates a well oxygenated, non acidic fetus with a normal fetal acid base balance
  • WE LIKE!!
  • Category 2 = indeterminate
  • not predictive of abnormal fetal acid base status, not enough evidence
  • Category 3 = abnormal 
  • predict abnormal fetal acid base status
  • NOT GODD --> ABNORMAL
  • ABCs FIRST
• Tachysystole: >5 contractions in a 10 min segment averaged over a 30 min period
• Leopold's maneuver: 4 steps= situation of infant, position of fetal back, presenting part, pelvic group - cephalic prominence
• 4 types of intrapartum monitoring: Auscultation, Palpation of contraction, external electronic fetal monitoring (EFM) and uterine monitoring, and internal electronic fetal monitoring (IEFM)