Anesthesia in Labor and Delivery

There are five types of anesthesia used in labor and delivery: local anesthesia, pudendal block, lumbar epidural block, subarachnoid (spinal) block, and general anesthesia.

Local Anesthesia:

• It is used for blocking pain during episiotomy
• It is administered just before the birth of the baby
• The anesthetic has no effect on fetus

Pudendal Block:

• It is administered just before the birth of the baby
• The anesthetic is injected into the pudental nerve through a transvaginal route
• It has effect last about 30 minutes
• It blocks the perineal area for episiotomy
• There is no effect on contraction or the fetus

Lumbar Epidural Block:

• The anesthetic relieves pain from contractions and numbs the vagina and perineum
• The anesthetic is injected in epidural space at L3 to L4 and may cause hypotension, so assess the maternal blood pressure
• The anesthetic is administered after labor is established or just before a scheduled casarean birth
• Keep mother in side-lying position or place a rolled blanket beneath the right hip to displace the uterus from the vena cava
• Administer IV fluids if prescribed
• Increase fluids if hypotension occurs

Subarachnoid (spinal) Block:

• The anesthetic is injected into the spinal subarachnoid space at L3 to L5 and administered just before the birth
• It relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities
• The anesthetic can cause maternal hypotension and postpartum headache
• Keep mother lie flat for 8 to 12 hours following spinal injection
• Administer IV fluids as prescribed

General Anesthesia:

• General anesthesia may be used for some surgical interventions
• It might cause a danger of respiratory depression and vomiting
• The mother is not awake

STAGES OF LABOR – Stage IV

LAST STAGE

• Last stage of labor begins with delivery of placenta and ends with postpartum stabilization
• Duration: usually 1-2 hours after delivery (primipara or multipara)
• Blood pressure returns to the pre-labor level
• Pulse is slightly lower than during labor
• Fundus remains contracted, in the midline, 1-2 fingerbeadths below the umbilicus

Nursing Interventions:

• Maternal assessment every 15 minutes for 1 hours, every 30 minutes for 1 hours, and hourly for 2 hours
• Administer oxytocin product if ordered
• Assess fundus every 15 minutes, if soft, massage with side of hand
• Assess lochia, checking peripad and under lower back
• Assess bladder for distention because full bladder will prevent contractions and increase bleeding
• Assess episiotomy for intactness and possible bleeding

STAGES OF LABOR – Stage III

THIRD STAGE

• Third stage of labor begins with delivery of infant and ends with delivery of placenta
• Duration: up to 20 minutes (primipara or multipara)
• Contractions occur until the placenta is born
• Placental separation and expulsion occur
• Birth of placenta occurs 5-30 minutes after birth the baby

Nursing Interventions:

• Assess maternal signs and uterine status
• Observe for placental separation
• Observe mother for signs of altered LOC or altered respiration (indicate aneurysm or emboli)
• Allow maternal-infant interaction as soon as possible

STAGES OF LABOR – Stage II

SECOND STAGE

• Second stage of labor begins with complete dilation and ends with delivery of infant
• Duration: 30-90 minutes in primipara and 15-20 minutes in multipara
• Cervical dilation complete
• Uterine contractions occur every 2-3 minutes, lasting 60-75 seconds and the intensity is strong
• Increase in bloody show
• Mother feels urge to bear down

Nursing Interventions:

• Assess fetal well-being continuously
• Monitor maternal vital signs
• Encourage pushing
• Encourage deep-full breath (not to hold breath longer than 5 seconds when pushing)
• Commend mother’s effort

STAGES OF LABOR – Stage I

First Stage

The first stage consists of three phases: latent, active, and transition. This stage begins with the first true contraction and ends with complete effacement and dilation to 10 cm.

Latent Phase (Early Labor):

• Duration: 10-12 hours in primipara and 8-10 hours in multipara
• Cervical dilation is 1 to 4 cm
• Uterine contractions occur every 15-30 minutes and are 15-30 seconds in duration and mild intensity
• Mother is talk active
• Encourage mother and partner to participate in care
• Change position and ambulation to comfort mother
• Offer fluids an ice chips
• Inform the progress to mother and partner
• Encourage voiding every 1-2 hours

Active Phase:

• Duration: 2-4 hours in primipara and 2-4 in multipara
• Cervical dilation is 4-7 cm
• Uterine contractions occur every 3-5 minutes and are 30-60 seconds in duration and of moderate intensity
• Mother becomes restless and anxious as contractions become stronger
• Mother may experience feeling of helplessness
• Encourage mother in maintenance of effective breathing
• Provide a quiet environment
• Inform the progress to mother and partner
• Backrubs, sacral pressure, pillow support and position changes to promote comfort
• Offer fluids and ice chips
• Instruct partner in effleurage
• Encourage voiding every 1-2 hours

Transition Phase:

• Duration: 2-4 hours in primipara and 1-2 in multipara
• Cervical dilation is 8-10 cm
• Uterine contractions occur every 2-3 minutes and are 45-90 seconds in duration and strong intensity
• Mother may becomes tired, restless, irritable, and feels out of control
• Encourage rest between contraction
• Inform the progress to mother and partner
• Provide privacy
• Offer fluids and ice chips
• Encourage voiding every 1-2 hours

Special Nursing Interventions First Stage:

• Monitor vital signs
• Monitor fetal heart rate via ultrasound Doppler, fetoscope or electronic fetal monitor
• Assess fetal heart rate before, during and after a contraction (normal FHR is 120-160 beats per minute)
• Monitor uterine contractions by palpating, determining frequency, duration, and intensity of contraction
• Assess status of cervical dilation and effacement
• Assess fetal station presentation and position by Leopold’s maneuver
• Assess the color of the amniotic fluid if the membranes have ruptured because meconium-stained fluid can indicate fetal distress

Fetal Heart Rate Monitoring

Fetal monitoring is the way to displays the fetal heart rate (FHR). Fetal heart rate is monitored in relation to maternal contraction. The baseline FHR is measured between contraction and the normal FHR at term is 120-160 beats per minute. The device that monitors uterine activity can assess frequency, duration and intensity of contractions.

There are two types of fetal monitoring: external fetal monitoring and external fetal monitoring.

External Fetal Monitoring
It is noninvasive procedure and is performed using a tocotransducer or Doppler ultrasonic tranducer. The ultrasound transducer is placed over the area in which the fetal back is located and fasten with a belt. The tocotransducer is placed over the fundus of uterus where contractions feel stronger and fasten with a belt. This external fetal monitoring will allow the client to get position comfortably.


Internal Fetal Monitoring It is invasive procedure and requires rupturing of the membranes and the electrode is attached to the presenting part of the fetus. For being available of internal fetal monitoring, the mother must be dilated 2-3 cm.

FETAL HEART RATE PATTERN

Fetal Bradycardia:
The FHR is less than 120 beats per minute for 10 minutes of more

Fetal Tachycardia:
The FHR is greater than 160 beats per minute for 10 minutes or more.

Acceleration
Accelerations are temporary increases of FHR at least 15 beats greater than the baseline and lasting at least 15 seconds, reflect a responsive nonacidotic fetus. Acceleration may occur with fetal movement, uterine contraction, vaginal examinations, or when the fetus is in a breech presentation.

Early Decelerations
In early decelerations, the fetal heart rate is below baseline and return to the baseline by the end of the contraction. It usually occurs during contractions and not associated with fetal compromise and requires no interventions. A uniform shape and mirror image of uterine contraction are showed.

Late Decelerations
In late decelerations, the fetal heart rate looks similar to early deceleration but begin well after the contraction begins and return to baseline after the contraction ends. Late decelerations reflect impaired placental exchange or uteroplacental insufficiency. The intervention includes improving placental blood flow and fetal oxygenation by placing patient on side, administer oxygen by tight face mask, discontinue oxytocin (if any), hydration, and correct hypertension (if any).

Variable Deceleration
In variable decelerations, the fetal heart rate does not have the uniform appearance. Shape, duration and degree of FHR fall below baseline are variable. Variable decelerations are significant when the FHR repeatedly decreases to less than 7- beats per minutes and persists at the level for at least 60 seconds before returning to the baseline. The cause of variable decelerations is the conditions that restrict flow through the umbilical cord (compressed umbilical cord). Interventions include change position (trendelenburg may be helpful), discontinue oxytocin (if any), check for cord prolapsed or imminent delivery by vaginal exam, consider amnioinfusion, and administer 100% oxygen by tight face mask.

Breathing in Labor

Breathing technique during labor and delivery will promote relaxation and oxygenation.

FIRST STAGE LABOR BREATHING

Cleancing Breath
Each contraction begins and ends with a deep inspiration and expiration.

Slow Paced Breathing
It is used as long as possible during labor, and promotes relaxation

Modified Paced Breathing
Breathing is shallow and fast, and it is used when slow paced breathing is no longer effective.
Pattern Paced Breathing (pant blow)
After a certain number of breaths, the client exhales with a slight emphasis or blow, and then begins the modified paced breathing.


Breathing to Prevent Pushing
Encourage client to blow repeatedly using short puffs when the urge to push is strong.

SECOND STAGE LABOR BREATHING

Traditional Pushing
The client takes on or more cleansing breaths at the beginning of a contraction and then hold it, pushing as hard as she can for as long as possible. Then quickly exhales, takes another breath and pushes again, repeating the process until the contraction is over.

Other Pushing Methods
The client exhales small amounts of air through an open glottis during pushing.
The client pushes in short bursts only when the urge is strong instead of using prolonged expulsive efforts.

Leopold’s Maneuvers

Leopold’s Maneuvers are methods to determine position, presentation and engagement of fetus.

They will include:

1. Determination of what is in the fundus
2. Evaluation of the fetal back and extremities
3. Palpation of the presenting part above the symphysis, and
4. Determination of the direction and degree of flexion of the head.

How to Perform Leopold’s Maneuver

Before performing Leopold’s Maneuver, ask the mother to empty the bladder, warm hands, and apply them to the mother’s abdomen with firm and gently pressure.

First Leopold’s Maneuver:

1. It will determine which part of the fetus is in the fundus.
2. Place pals on each side of the upper abdomen and palpate around the fundus
3. You would feel a hard, round, movable object if the head is in the fundus
4. You would feel soft and have an irregular shape and are more difficult to move if the buttock is in the fundus

Second Leopold’s Maneuver:

1. Move hand downward over each side of the abdomen, applying firm, even pressure.
2. The fetus’s back which is a smooth, hard surface should be felt on one side of the abdomen.
3. The hands, feet, elbows, and knees which are as irregular knobs and lumps will be felt on the opposite side of the abdomen.

Third Leopold’s Maneuver:

1. It will determine fetal position
2. Place hand above the symphysis pubis
3. Bring thumb and fingers together and grasp the part of fetus between them that may be the head or the buttocks

Fourth Leopold’s Maneuver:

1. It is used in the late stage of pregnancy to determine how far the fetus has descended into the pelvic inlet.
2. Place hand on the sides of the lower abdomen close to the midline
3. Slide hands downward and press inward
4. If you have determined that the buttocks are in the fundus, then feel for the head
5. If you cannot feel the head, it probably has descended

Mechanism of Labor

There are eight classical steps in the normal mechanism of labor as following here:

Engagement

• This is also called lightening or dropping
• The fetus nestles into the pelvis

Descent

• This process starts from the time of engagement until birth and is assessed by the station.
• The fetal head undergoes as it begins its journey through the pelvis.

Flexion

• The fetal head’s nodding forward toward the fetal chest
• While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller structure to pass through the maternal pelvis

Internal Rotation

• With further descent, the occiput rotates anteriorly and the fetal head assumes an oblique orientation. In some cases, the head may rotate completely to the occiput anterior position.

Extension

• It begins after the head crowns
• This means that the fetal chin is no longer touching the fetal chest.
• It enables the head to emerge when the fetus is in a cephalic position
• The extension of labor is completed when the head passes under the symphysis pubis and occiput and the anterior fontanel, brow, face and chin pass over the sacrum and coccyx and are over the perineum

Restitution

• After the head emerges, the fetal head becomes in a realignment

External Rotation

• The shoulder of fetus externally rotates after head emerging and restitution
  
• The shoulder is in the anteroposterior diameter of the pelvis.

Expulsion

• This is the birth of entire body.

Fetal Presentation

Fetal position is defined as designation of landmark of fetal presenting part (occiput, mentum, sacrum, scapula) to right or left, and anterior, posterior, or transverse portion of the woman's pelvis.

A three-letter abbreviation is used to describe the relationship of the presenting part to the maternal pelvis.

• Sides of presenting part facing in the pelvis are described as: R (right) or L (left).
• Landmarks of presenting part are described as: O (occiput, or head), S (sacrum), Sc (scapula, or shoulders), M (mentum, or chin).
• Directions of presenting part facing in the pelvis are descreibe as: A (anterior, or front), P (posterior, or back), or T (transverse).

The first and third letters relate to the pelvis, and the second letter relates to the fetus.


Common possible fetal presentations are :

VERTEX / OCCIPITAL PRESENTATION
LOA = Left Occipital Aterior
LOT = Left Occipital Transverse
LOP = Left Occipital Posterior
ROA = Right Occipital Anterior
ROT = Right Occipital Transverse
ROP = Right Occipital Posterior

FACE PRESENTATION
LMA = Left Mentum Anterior
LMT = Left Mentum Transverse
LMP = Left Mentum Posterior

BREECH PRESENTATIONS
LSA = Left Sacrum Anterior
LST = Left Sacrum Transverse
LSP = Left Sacrum Posterior


Here are images of fetal presentation :



click image to enlarge.

Labor: True and False

There are pleliminary events to labor :

• Backache
• Cervix becomes soft and effaced and may begin to dilate
• Braxton Hicks contraction increase
• Lightening or dropping
• Membranes may rupture spontaneously
• Vaginal secretions increase
• Urinary frequency increases
• Passage of mucous plug occurs
• Weight loss of 1 – 3 lb
• “Bloody show” occurs
• Mother has a sudden burst of energy

How to differentiate between true labor and false labor?

True Labor:

• Contractions are in the back and abdomen
• Contractions are regular with decreasing intervals
• Contractions increase over time and increase with walking, and little or no effect from sedation
• Cervical dilation and effacement are progressive

False Labor:

• Contractions are in lower abdomen
• Contractions are irregular with unchanging or increasing intervals
• Contractions remain the same, unaffected by, or decrease with walking and relieved by sedation
• No dilation or effacement or cervix