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Labor and the Birth Process
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  1. Labor and the Birth Process

  2. The 5 “Ps” of labor • Passenger • Passageway • Powers • Position • Psychologic response

  3. Passenger’s Head

  4. Presentation of the Passenger • What is the fetal presentation? • Cephalic (96%) • Breech (3%) • Shoulder (1%)

  5. Fetal lie

  6. Fetal Attitude

  7. Position of the Passenger

  8. Station & Engagement

  9. Passageway

  10. Passageway Continued

  11. Powers-Primary • We really do not know what causes the primary powers ContractionFrequency, Duration, and Intensity Result in Effacement and Dilatation

  12. Secondary Powers

  13. Positioning

  14. Pelvic muscles/ligaments

  15. A bit of humor found • http://www.youtube.com/watch?v=ppzV6hoPkIc

  16. Pain Management in Labor

  17. Pain Perception & Expression • Pain thresholds are similar in everyone, the perception of pain is not. • Pain is expressed • Sensory • Emotionally • Physiologically

  18. How Does Labor Effect Pain • Pain experienced by mother can result in : • Acidosis of the fetus • Impaired Uterine Contraction

  19. Non-Pharmacologic Strategies • Position changes • Walking • Rocking • Labor ball • Breathing • May need to breath with mother • Counter-pressure • Application of heat or cold • Showering/Tub • Music • Aromatherapy • Imagery • Focal points • Effleurage • Therapeutic touch • Childbirth Education • Hypnosis • Biofeedback • Empty Bladder regularly

  20. Pharmacologic Goal maximum relief with minimal risk to mother and fetus

  21. Pain Control Depends: • Epidural • Spinal/Epidural • Nerve Block • Local • Pudendal • Spinal • Epidural • Combined Spinal/Epidural(CSE)

  22. Analgesics 1st Stage • Systemic analgesia • IM vs IV • Narcotics Opioid agonist • Demerol, Fentanyl, Morphine • Opioid agonist-antagonist • Stadol, Nubain, Narcan • Epidural

  23. Naloxone (Narcan) • Opiate antagonist • Works immediately-may need to be repeated • Used to counteract respiratory depression-Neonatal dose available at every delivery • Adult dose: 0.4-2mg IVP • Neonatal dose: 0-1mg/kg of 0.4mg/ml concentration • Do not give to patient with narcotic dependency-triggers immediate withdrawal and possible seizures

  24. Labor Nerve Block Meds

  25. Pain Pathway

  26. Epidural Coverage

  27. General Anesthesia Only used in an emergency prior to infant delivery, if patient has contraindications to a Spinal /Epidural, or demands to be put to sleep.

  28. Fetal Circulation • Maternal position • Uterine Contractions • Blood Pressure • Umbilical Blood Flow Kahn Academy

  29. Fetal Assessment Continuously or intermittently

  30. Fetal Monitor Tracing

  31. Monitor placement and Lie

  32. Intrauterine Pressure Catheter-IUPC • IUPC use • Montevideo Units (MVU) • Subtract baseline pressure from peak pressure for each contraction in a 10 min period. 100-250 is optimal

  33. Fetal Heart Rate • Normal FHR Baseline110-160 • 10 minute segment with no significant periodic changes or change in baseline of >25 BPM • Variability • Absent • Minimal • Moderate • Marked (pg 421)

  34. Fetal Heart Rate • Tachycardia >160 • Can be early sign of fetal hypoxia • Maternal or fetal infection • Maternal hyperthyroidism or fetal anemia • Response to some drugs-cocaine, Meth, terbutaline, Vistaril • Bradycardia <110 • Heart Block • Viral infections such as CMV

  35. Periodic & Episodic Changes • Periodic-with contractions • Episodic-occur without contractions • Acceleration 15 x 15 above baseline • Deceleration • Early • Late • Variable

  36. What type of deceleration?

  37. What type of deceleration?

  38. What type of deceleration would this cause True knot in cord

  39. Variable deceleration

  40. Management of FHR tracing • Basic interventions • Oxygen • Reposition • IV fluid bolus • Specific problem • Correct the problem • If can not…..DELIVER BY CESAREAN

  41. Categories of FHR tracings • Category I-normal • Category II-requires interventions and close monitoring • Category III-Deliver

  42. Category I • Normal FHR:110-160 • FHRV: Moderate (6-25beats) • Accelerations or Early Decelerations: Absent or present • Late or Variable Decelerations: Absent

  43. Category III • FHRV: Absent + Recurrent late decelerations • FHRV: Absent + Recurrent variable decelerations • FHRV: Absent + Bradycardia • Sinusoidal

  44. Category II • Bradycardia without absent FHRV • Tachycardia • FHRV: Minimal or Marked • FHRV: Absent without recurrent decels • Absent accelerations after induced fetal stimulation (this is only diagnostic-not intervention) • Recurrent variable decel + FHRV: Min or moderate • Prolonged decel> 2min but <10 min • Recurrent late decel + FHRV: Moderate • Variable decel with other characteristics: Slow return to baseline, overshoots, or shoulders

  45. Category II Example

  46. Review

  47. Review

  48. Review

  49. Review

  50. Remember the Psychosocial • Labor is anxiety provoking • Is the baby going to be ok? • Was this pregnancy planned? • Does the patient have adequate support both at home and in labor? • Will she have help at home when goes home with infant?