Intrapartum Nursing: Labor Stages, EFM Interpretation, and OB Emergencies

Okay, so last mini lecture for intrapartum content. This is going to be a synopsis of high points we'll call it.

So not that this is new content or not that this is um necessarily all-incclusive of content that uh we

need to understand for the exam, but we're going to hit on the high points of the larger picture pieces that we've

discussed and applied in class. So to begin inch part we're talking about labor. So how do we define true labor?

Remember that is um two parts we have to have contractions that are progressive in nature. So um increasing in

intensity, increasing in frequency, increasing in duration that are causing cervical change. So we have dilation or

aacement um or drop down of station for the fetus um in the birth canal. And it doesn't need to be all of those things,

but we have to have some kind of change occurring to the cervix as a result of progressive contractions to deem a

patient in labor. And then when we look at what three assessments are included in a sterile vaginal exam or cervical

assessment, we know that we are looking at dilation, easement, and station. So dilation being how open the cervix is.

Remember, we measure that in centimeters, and we're going from closed to 10. Easement is how thick and or thin

that the cervix gets throughout the labor progress. Um, and remember that one's measured in percentage. So, we're

going from thick all the way to 100% of where there's no um no width or length left of the cervix when we're ready to

deliver when we're fully completely dilated. And then fetal station being fetal uh the fetus's presenting part

ideally for vaginal delivery is ahead, but whatever presenting part we have. And then the relation of that presenting

part to the isial spines of the pelvis for the laboring woman. And we know that we have negative numbers, which means

baby's still really up high in the pelvis. Zero, meaning baby's presenting part is even with the issial spines,

essentially closing off the exit to anything except baby. And then positive numbers, meaning baby is on the way out

for delivery past just engagement. Um, in that we usually get to about plus 2 to + 3 is when we see crowning visually

from external. And then our four stages of labor. So we know we have stage one which is the

labor process itself, the dilation part. So we're from the beginning of contractions and cervical change

occurring all the way through to where we completely dilate. Um and that is our starting point for stage two. Stage two

is the pushing or the um waiting to push if we're laboring down and we're in that latent phase. Um stage where we are

starting with full dilation and ending with delivery of baby. Stage three is our delivery of the placenta. Ideally

happens within less than 30 minutes. And then stage four is the postpartum recovery period for mom. So those are

our four stages. And then we know that our first and second stage have phases. So the first phase of the first stage is

our latent phase. That is all the way up to 5 cm dilated. Contractions are usually not super super close together.

Um they might be irregular in both frequency and duration. There is some type of of cervical change happening and

the patient during the latent phase of stage one is usually still able to talk and hold conversation especially in

between contractions. They are comfortable or at least not severely in pain breathing through contractions when

they're occurring. This is the time that they are most receptive to information, to education, to um looking ahead as to

what what to expect next. That is the time where we try to get all of those those tasks and um objects completed.

And then stage one phase two is our active labor. So 6 cm or more in dilation usually much more aacement um

contractions are closer together, stronger, lasting longer, more rhythmic in nature or more regular in nature. Um

and then we have that to you know from 6 centimeters on remembering that our patients who do not have an epidural or

any type of anesthesia. Um often also experience transition phase which is in that 8 to 10 cm right towards the end.

Um and a lot of times that is accompanied by nausea and vomiting um turning inward. I can't do this. I want

to go home. those kind of statements um usually means it's about to they're about to um the first and second phase

of stage two is just the difference of if we are fully dilated and pushing which would be our active phase or we're

fully dilated and we're waiting to push because we don't have the urge or the epidural is blocking that urge and

there's no urgency to do that. Um, also remembering that if a patient does not have an epidural stage 2 latent

phase really probably not going to happen much for them. So our labor assessment remember we said

we have we're always going to start with vital signs are a are a critical component of any any patient assessment.

So we need to um obtain vital signs and we need to know what our normal ranges is are for vital signs. we are going to

ask the patient about pain. Um and then along with that knowing that what we are doing for pain andor support during the

labor process will vary patient to patient. Um we need to know what is what is acceptable methods of pain control

both non-farmacologic and pharmacologic. Um we need to know the difference between anesthesia and analesia. Right?

So we have our epidural spinal or general anesthesia and then we have our analesics pain control. um via other

medications that are mostly systemic in nature. Our intraartum five, so we talked a little bit about that pain

piece. And then we have our contractions, leaking, bleeding, and fetal movement. So remembering that pain

is both subjective. We're asking the patient and then we need to follow up with descriptors, location, um what kind

of pain, a 0 to 10 scale for pain, um because that pain might not always be related to labor pain itself. um our

contractions, subjective and objective measurement. Same for leaking of fluid and vaginal bleeding. If our patient has

had rupture of membranes, we need to know the time that it occurred and what color the fluid was. Um if the patient

is experiencing vaginal bleeding, that is never to be assumed normal, but it also doesn't mean that something is

catastrophically wrong. Um remembering that bloody show and vaginal bleeding are

different things. Bloody show is more of a red tingy mucus um that is common as the cervix dilates and a faces and

especially with um manipulation from vaginal exams that increases bloody show. Um vaginal bleeding bright red

bleeding is not to be assumed normal and needs further investigation. Then we have our EFM and contraction

interpretation and remembering what we what the different categories are we look at for both of those and then what

we do or intervene upon based on our findings. So for our fetal heart rate we know we are starting with our baseline

first and foremost always average essentially of our fetal heart rate rounded to the an increment of five. So

ending in a zero or five we would like that baseline to be between 110 and 160 cuz that's our normal range. After we

determine baby's baseline, we look at variability, remembering that we have four categories of variability. Um,

marked variability means we probably couldn't determine a baseline to begin with. So, that would be um an easy

checks and balance system for us. And then the other three categories of variability being moderate, minimal, or

absent. Absent meaning none at all, flat line, no jagged, no um no beat to beat changes. We don't get that back and

forth. Um minimal being less than five beats, but so one to five, right? because if it was zero it would be

absent. 1 to 5 for minimal and then 6 to 25 being our moderate which is the um category of variability we would like to

see accelerations meaning fetal heart rate speeds up. We know we're looking for 15

by 15. So we want 15 beats higher than baseline and we want that um acceleration to last at least 15

seconds. So from the time the fetal heart rate leaves baseline until the time it returns to baseline should be at

least 15 seconds. And that would be considered an acceleration. Accelerations caused by oxygenation. We

love an oxygenated fetus. So we mark that those are there. We are reassured and we continue on. Decelerations

meaning the exact opposite. So instead of accelerating, we're decelerating. The fetal heart rate is slowing down. And we

know that we have various different kinds of decelerations. And the type of deceleration tells us what the cause of

the deceleration is. So variable decelerations caused by chord compression. The ones that look like

these, very sharp, abrupt to decrease, very um quick return to baseline. Our early decelerations are caused by head

compression. So our earies and our late, remember, often the same shape or look very similar in shape. They're flat U

shapes instead of that variable sharp V. Um our early decelerations caused by head compression. Those decelerations

are going to mirror the contractions. So the the deepest point of the deceleration is going to match up with

the highest point of the contraction and those are caused by head compression and we don't have to do anything about

them except document and continue on. Late decelerations look again the same shape as our earies. However, they uh

deceleration begins after the contraction has started and the baby's baseline or the baby's heart rate does

not return to baseline until well after the contraction is over. It comes back to baseline late. That's how we

determine it's a late deceleration. Late decelerations are caused by placental insufficiency and should always always

warrant intervention of some sort. Our contractions, we are looking at the frequency of duration or frequency of

contractions, meaning start of one contraction to the start of the next. Duration being the start to end of each

contraction. And both of those things can be a range. They're not um always the exact same when we're looking at a

strip. So a range is fine. For frequency, that's usually a range of minutes. And for duration, that is more

frequently a range of seconds. Intensity and resting tone. Um, you note that we have a little asterk by those. Those

those are going to require palpation to objectively assess if we are using external monitoring, which we mostly do.

So, remember that the um the nurse needs to palpate during the peak of a contraction for intensity and the um

resting tone would then be between contractions. We hope to feel that the abdomen is soft. That means everything

is relaxed and there's adequate blood flow and oxygenation going to the fetus in between.

So we talked um through intrauterine resuscitation in class and we looked at some strips and we kind of applied which

pieces um or which interventions within uh intrauterine resuscitation are warranted based on fetal changes and

what those changes are. Um so ones we know again not all-incclusive but we know that if we have variable

decelerations uh that's cord compression our easiest and most non-invasive intervention for that is to change mom's

position change the position we change the pressure on the cord we can alleviate those variable dels um if we

have late decelerations uh that indicates the baby is not tolerating those contractions well if we have

ptocin it needs turned off um if mom is um not well oxygenated we can give extra oxy oxygen for that we can um increase

IV fluids, change her position, try to improve the profusion and or oxygenation of the blood flow to the uterus which to

the placenta to baby. Um if we have minimal or absent variability, we can't do a lot about um

depression of the central nervous system from the outside aside from not giving mom meds that would do that. But we can

influence oxygenation. So we can give oxygenation for minimal or absent variability. Hyper oxygenate mom

theoretically which pushes more oxygen to the fetus and then improves our variability. So those are some examples

that we talked about. Um remembering that we always want to be able to identify what the rationale is for any

intervention. Um and that will help you decide based on the change that you're seeing what the appropriate intervention

is. Um for example if we have fetal tacoc cardia um but we have moderate variability no d

cells no axels but we have fetal tacic cardia um giving mom oxygen is not warranted because we have moderate

variability and oxygen is not going to change the fetus's baseline. Therefore that's an unnecessary intervention.

Right. Um, we said that fetal tacic cardia is most often, if not always, caused by maternal fever. So, what we're

going to do in regards to maternal fever is we're going to give her medication to treat whatever is causing her fever,

which is more than likely an infection. We're going to treat the infection. If we bring down her fever, we decrease her

body temperature. Baby's baseline will then decrease as a result. And then we have a normal range baseline.

We talk about our complications. We have we know we have some that are concerning and then some that are emergent. Right?

So these are more our emergent scenarios. Um an umbilical cord prolapse signs and symptoms of that would be an

abrupt severe variable deceleration that is either extensively long and or results in fetal brada cardia because

the compression of that cord is not being relieved if we have a true cord prolapse. Um what we do about that we

elevate whatever the presenting part is. We turn off the toin if it's running. We bololis fluids. We give oxygen. We

position mom um in a trendelenberg position or on their hands and knees to try to help gravity pull the weight and

pressure from the fetus off of the umbilical cord. We use our hand, elevate that presenting part off the cord to

decrease that pressure and then we proceed for an emergency C-section. Um we hopefully by the time we identify

that there is a cord prolapse we are in the we are in the O delivering that baby within like 10 minutes or less would be

ideal for a shoulder dystocia when baby's shoulder gets stuck on the way out. Um so we cannot diagnose the

shoulder dystocia until after the head is delivered and then the shoulder gets stuck and we have specific interventions

that we um need to apply for that. Mc Roberts is a very um initial intervention that's when we have

maternal flexion of the legs. So essentially pushing her legs all the way up to her ears as as far as it can go.

The rationale for that is that it opens the pelvic outlet as much as it can possibly be to hopefully relieve um the

stuck shoulder. Uh in addition to that super pubic pressure, so pressure of the nurse usually right above the pubic bone

of mom, pushing ideally on baby's shoulder to pop it underneath that pubic bone. Um that's going to help dislodge.

Um if those things don't work, we can flip mom on her hands and knees. There are internal maneuvers that the

physician can do to try to get baby unstuck. Um, some of them more invasive as we go along, but we know that we have

a 5minute kind of time limit from the time baby's head's delivered and we diagnose the shoulder dysia to get baby

out without really really poor outcomes related to hypoxia and tissue eskeeia and irreversible

brain damage. Um, other emergent situations non-reassuring fetal heart tones. So always are category 3es,

right? anything that warrants a category 3 strip warrants a like if we can't fix it right now we need to deliver and then

I would also add to that that we have if we have a concerning category 2 strip that we are still in category 2 but we

have done all of the interventions we can andor know how to do um and we're not seeing an improvement that that

fetal heart rate is non-responsive um that is probably going to warrant an emerent situation

so Then we look at amniotic fluid embolism which we know is one of the um most severe medical emergencies

in OB that is um the mortality rate of which is extremely high for mom and also for subsequently then baby if it is um

if it occurs prior to delivery. So we think of amniotic fluid embolism sort of in the way that we we think of a

pulmonary embolism, but it isn't the same reaction. So it's an embolism in the fact that there is a small amount of

amniotic fluid that is pushed into the circulatory system during labor and or delivery or shortly after. Uh however,

it is not an embolism that it causes a blockage of some sort to some part of the body that then causes the squellle

afterwards. It is the body's reaction to the amniotic fluid in the circulatory system. Um, which is almost like a

it sees it as a foreign object almost to the point of like an anaphylactic allergic reaction. However, it's not

it's not the same as that. Um, that's just the most the closest thing I think we can um liken it to. But it is a

severe reaction of the body to the foreign substance of which is the amniotic fluid in the circulatory system

that causes a cardopulmonary collapse. Um so if our patient is exper experiencing an amniotic fluid and

embolism, the signs and symptoms are going to somewhat fall in line with what we would expect

for a pulmonary embism is that they they feel like they have shortness of breath or they're having trouble breathing or

they might experience chest pain. They have an overwhelming sense of doom. Um that something is not right even if they

cannot verbalize what is not right or what is wrong. Uh and then they collapse. They uh their heart they will

go into cardiac and respiratory arrest. Um it is very sudden. It is very severe. It will require CPR. It will require a

full code. It will often require um intubation and transfusion of blood products and an admission a lengthy

admission to an ICU um to support the patient's recovery. If this occurs prior to delivery during the labor process,

usually stage two, um it is expediently required that we deliver the fetus as quickly as possible. Um and then we need

to alert all of the people. This is the full code blue situation. You want as many hands on deck as possible. Um, so

you realizing that CPR and quick notification to all of the interdisiplinary personnel that we need

to take care of this patient are our top priorities. Um, uterine rupture most likely um

occurring for a patient who has had a previous uh incision and scar on their uterus. Most likely that's a cacaian.

doesn't have to be. They could have had a momectomy or some other type of um surgical procedure on the uterus which

of which leaves a scar on the muscle. Um but most frequently it's a previous cacaian um whether they're trying to

vacc um or that we just got really careless with the use of arptocin and we weren't

monitoring appropriately or whatever that might be. Uh we see a an abrupt cease in contraction activity, uterine

contraction activity. We see a severe and abrupt change to the fetal heart rate that usually ends up in brada

cardia. We see changes in mom's vital signs that indicate an intraartum hemorrhage of some sort. Uh i.e. blood

volume leading the circulatory system. So our decreased blood pressure, increased pulse, increased respiratory

rate, decreased O2 saturation. Um the mom may or may not stay conscious for an extended period of time

depending on how severe the abruption is and how much blood loss occurs very quickly. Um but we will be moving

towards delivery expediently. Um there is usually a good deal of vaginal bleeding associated with this. Uh a lot

of times you can palpate the fetal parts through the abdomen because they're no longer in the uterus. Um but this is

definitely one of the emergency situations in which an emergency delivery and then stabilization is

required. Um and then addition to that the intrapartum hemorrhage that can uh stem from an abrupted placenta where the

placenta separates from the uterine wall prematurely or from the rupture of a vasa previous situation. Um again all

treated very similar emerent cesarian delivery stabilization um and control of bleeding and support

for recovery. So then we have our non-emerent which is urgent situations um in which

we are not in an emergency situation. However, uh there are many interventions needed. Some of them more urgent

intervention. Um and we want to monitor the progress of labor for these different complications.

So, see pelvic disproportioning that that essentially means baby's head is not conducive for mom's pelvic size and

therefore won't be exiting the vaginal route. Uh we often in we often pick up that this could be an issue when we have

failure of the fetus to descend into the pelvis. uh failure to get to that zero station. And this warrants um a

C-section delivery. Not necessarily that it needs to be emergent. Baby's tolerating everything well and still

looks reassuring on the monitor. It can be, you know, as soon as possible kind of thing, but it doesn't need to be a

general anesthesia emergency situation. Um II intramniotic infection or coro. Um coro is the old term, II is a new term,

but essentially means an intrauterine infection. So, an infection has um been diagnosed in the uterine cavity while

baby is still on the inside during labor. Uh this is going to require antibiotic therapy, fluid resuscitation

as far as like replenishing fluid. Mom usually has a fever. Uh baby will likely be tacocartic at some point during

labor. Um we might see an elevated white count. We might test the fluid. All of the things that go along with infection.

Um but we want baby delivered sooner rather than later in that situation. prolonged labor. So again, depending on

if that's prolonged first stage or prolonged second stage tells us what the cause or underlying um underlying

rational for that might be and then that often tells us what if there's anything we can do to fix it.

Mcconium stain fluid baby passing mononium while still in uterero um we might we always know note that it's

there. Um the provider needs to know um NICU or special care whoever might be helping with baby resuscitation after

delivery needs to know. um it increases the risk for aspiration and pneumonia and mechanical obstruction for breathing

for baby after delivery. It's not so much something that we need to um it's not going to impact

really severely usually um the actual labor process. We usually start to see baby have issues after delivery with

this. Although we could have um the theory is that babies passonium in uterero because of a stressful invent

event or environment or hypoxia something like that. So we might see changes on the fetal monitor that

indicate the fetus is distressed that led to the passing of mononium. It's not usually that the mcconium is actively

causing an issue in the fetus while they're in utero. Um and then operaginal deliveries. So, if we're using a vacuum,

remembering we get three pulls, three strikes are out, um that we might see some marks on the fetal head afterwards,

that we need to educate mom about what it sounds like if it pops off, how many times we'll try, what is normal,

abnormal, um watching the fetal heart rate strip, when is it indicated that we can do a vacuum delivery, um what

findings do we need to be able to see before we would try that. Same thing for forceps. forceps being even more um

invasive and problematic as far as risks associated to both mom and baby for tissue damage and lacerations and

bleeding um and all of those pieces. So again, all of these should include informed consent to the patient prior to

applying any of those that there should be a full risk benefits discussion on what the risks are um and then what

happens if we don't do this as evidenced by you know what what the situation calls for. Um so all of the that should

should be discussed prior to and then knowing the risk that it increase when we use either of those um to look for in

mom and or baby after delivery and that is our is our little synopsis for interpartum. So again it's not in

all inclusive that is not everything we could need to know for the exam but that is um a quick synopsis of all the high

points for the different various pieces that we're looking at. So if we understand that well we can apply that

knowledge to all of the different um pieces that we are going to be looking at at on the exam and in clinical and in

simulation.