Understanding True vs
. False Labor: Key Differences Explained
School
Grambling State University**We aren't endorsed by this school
Course
NUR 219
Subject
Nursing
Date
Dec 10, 2024
Pages
10
Uploaded by Lateria1
True versus False labor(SATA)➔Not all contractions indicate labor.➔Amniotic fluid has nothing to do with labor, contractions, or cervix changing.➔Cervix has to start dilating and effacing.➔True Labor- felt in the lower back◆Characterized by contractions occurring at regular intervalsthat increase in frequency, duration, and intensity.●Timing-○Regular, becoming closer together, 4-6 minutes apart, lasting 30-60 seconds.●Strength-○Becomes stronger with time, vaginal pressure usually felt.●Discomfort-○Starts in the back and radiates around toward the front of the abdomen.●Change in Activity-○Contractions continue no matter what positional change is made.●Stay or Go?-○Stay home until contractions are 5 minutes apart, last 45-60 seconds, and are strong enough so that a conversation during oneis not possible– then go to the hospital or birthing center.➔False Labor-◆condition during the latter weeks of some pregnancies when irregular uterine contractions are felt, but the cervix is not affected.◆Many women fear being sent home from the hospital with false labor.◆May feel anxious when feeling contractions, but education should be provided about the false labor contractions and the process especially if it's the first pregnancy◆Encourage women to think of false labor or prelabor signs as positive◆With the first pregnancy, the cervix can take up to 20 hours to dilate completely.●Timing-○Irregular, not occurring close together●Strength-○Frequently weak, not getting stronger with time or alternating (strong one followed by weak one)●Discomfort-○Usually felt in the front abdomen.●Change in Activity-
○Contractions may stop or slow down with walking or making a position change.●Stay or Go-○Drink fluids and walk around to see if there is any change in the intensity of the contractions; if the contractions diminish in intensity after either or both, STAY HOME.Passenger : ●Molding-○the changed (elongated) shape of the fetal skull at birth as a result of the overlapping cranial bones.○The swelling will disappear within 3-4 days*** TOTALLY NORMAL●Sutures play a role in helping to identify the position of the fetal head during a vaginal examination.◆Fetal Presentation-●***Feeling head, sometimes hand/arm is in the way●***Shoulders will not fit through the pelvis first.●The head of the fetus is the 1st part of the fetus to enter the pelvic inlet◆Fetal Station-●***Cervical exams are based on the baby's position by feeling the bony parts of the pelvis.○Nurses document and relay to the provider○We want to see this because we know that the baby is descendingout of MAMA.●Position (Maternal)◆Upright position: ●Decreases labor time, increases rate of vaginal delivery, increases comfort, gravity assist fetus to move downwardWalk around, sit up in different positions, birthing balls Basic client preparation➔Psychological response:factors promoting a positive birth experience include:◆Clear information about procedures◆Support: not being alone◆Sense of mastery, self-confidence◆Trust in staff caring for her◆Positive reaction to the pregnancy◆Personal control over breathing
◆Preparation for the childbirth experience ➔Strong sense of self and support during labor is important➔Safe and secure= self of control (pain levels)◆Suggest prenatal classes for sense of control➔EDUCATION- BREATHING TECHNIQUES➔Prenatal Education◆Help manage labor process◆Feeling in control◆Less medical intervention required◆Less likely to require analgesia or anesthesiaLess likely to have cesarean birth Table 13.2 Stages and phases of labor➔First Stage- Dilation (Longest stage)◆Time where being admitted and educated - make/go over plan●Once you get to active labor◆Progressive dilation of cervix◆Ends when cervix is 10cm dilated➔Second Stage-Expulsive◆Pushing phase➔Third Stage- Placental◆***Skin to skin contact●to promote positive transitioning for the newborn.◆MONITOR FOR HEMORRHAGE!!!***◆Pictocin after the placenta is delivered●bolus to clamp uterus down➔Fourth Stage- Restorative◆FOCUS: Monitor for hemorrhage, bladder distention, venous thrombosis●q15min assessments for 1 hour**◆Mother is usually thirsty and hungry at this stage●limited sense to acknowledge dull bladder or to void.**Vaginal examination(SATA)➔Purpose is to assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status ◆to gather information on presentation, position, stagnation, degree of fetal head flexion, and presence of fetal skull swelling or molding ➔Woman on her back during the exam- water is used as a lubricant ◆the cervix will be palpated to assess dilation, effacement and position
◆if the cervix is open= fetal part, position, station, and presence of molding can beassessedPerforming Leopold maneuvers➔Determining the presentation, position, and lie of the fetus***Fetal assessment during labor and birthAnalysis of amniotic fluid SATA➔Spontaneous or artificial rupture ➔Should be clear and not foul smelling➔CLOUDY or FOUL SMELLING- indicated infection➔GREEN- indicates passed meconium (babies first bowel movement still in utero)➔At 42 weeks, placenta starts to degrade and lose its function-causing issues. Analysis of fetal heart rate➔Hear most clearly at fetal back; lower quadrant, at or above the umbilicus➔➔Table 14.1 Interpreting Fetal Heart Rate Patterns◆FHR Decelerations: EARLY-NO INTERVENTION REQUIRED***➔FHR Decelerations: LATE-◆ALWAYS CATEGORY II or III and require INTERVENTION***●Intrauterine resuscitative measures●Move mom into a lateral position on the left side- to increase blood flow to the baby to decompress the artery.●IV fluid bolus●Place mom on oxygen●Pushing to improve fetal oxygenation●D/C oxytocin●Get baby out/do C-section- Life threatening to baby!!Non pharmacologic measures(SATA)➔Usually simple, safe and inexpensive to use◆Continuous labor support**●many benefits for the mother and newborn due to reduction of anxiety●provides emotional support, comfort measures, advocacy, information and advice and support for the partner ◆Hydrotherapy**●external use of any water for health promotion- shower/soaking in tub◆ambulation and position changes**●changing positions frequently (every 30 min) - sit, walk, kneel, stand, lyingdown, on hands and knees, birthing ball - all help to relive pain
●can help speed labor by adding the benefits of gravity and changes in pelvis○supine positions should be AVOIDED- can compress the vena cava and decrease the blood return to the heart●swaying from side to side, rocking or other movements can be comforting◆Application of Heat and Cold**●heat to the back, lower abdomen, groin and perineum○hot water bottle, warm compress○cold therapy- back, chest or face◆Attention focusing and imagery**●woman can focus on tactical stimuli like touch, massage or stroking (PETTING LEAH PETTING) - haha Brit lololol●Breathing, relaxation, positive thinking, positive visualization ◆Effleurage and Massage**●Effleurage= light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions●both use a sense of touch to promote relaxation and pain relief ○massages to increase the production of endorphins in the body◆involves manipulation of the body’s soft tissue◆Breathing Techniques**●effective in producing relaxation and pain relief through the use of distraction○controlled breathing helps reduce the pain experienced by the stimulus-response conditioning➔Pharmacologic measures➔Opioids:◆morphine-◆causes a decrease in FHR variability identified on the fetal monitor strip Continuing assessment during first stage of labor(Important to know!!!)➔Assess the woman’s knowledge, experience and expectations of labor◆BP, pulse and respirations are assessed every hour during the latent phase of labor◆during active phase of labor- vitals are assessed every 30 min●temp every 4 hours and then every 2 hours after membranes have ruptured➔Vaginal examinations are performed to track labor progress◆shared and reinforced that she is making progress toward the goal of birth◆uterine contractions are monitored for frequency, duration and intensity every 30-60 min during latent and then 15-30 during active phase◆determine their level of pain and ability to cope and use relaxation
➔When fetal membranes rupture, assess FHR and check amniotic fluid for…◆color◆odor◆amount➔Assess fetal Heart rate every 15- 30 min during active phase ◆also assess the FHT BEFORE ambulation/procedures/administering analgesia Birth: Nursing interventions➔The 2nd stage of labor ends with the BIRTH➔Provider will suction the newborn’s mouth FIRST ➔Nursing Management During the Third Stage of Labor, up to continuing assessment-Skin to skin contact immediately after birthUterine involution➔, then descends 1 cm (1 fingerbreadth) per dayUrinary system adaptations(SATA)- pretty sure there were more then what we listed :/ ➔Potential for urinary retention: fundus is displaced to the right and above the umbilicus◆When fundus is not firm -> called Boggy ➔Diuresis: rapid swelling of bladder after birth ◆get that bladder empty…or else…➔Ask them how it's going (lol?) ◆when’s last time you urinated?◆hows ya flow ➔Many have difficulty feeling the sensation to void after giving birth ◆difficulty voiding can lead to urinary retention, bladder distention and UTI➔Normal functions will return within a month after birth!➔Voiding sensation affected by:◆hematomas, perineal lacerations, generalized swelling, decreased bladder tone◆diminished sensation of bladder pressure due to swelling➔Integumentary system adaptations-Diaphoresis (SWEATING)◆(especially at night) to reduce body fluid levels retained during pregnancyRespiratory System Adaptations-➔Abdominal organs return to pre-pregnancy positions➔Anatomic changes of thoracic cavity and rib cage resolve quickly ➔Discomforts of pregnancy such as SOB, are relievedMusculoskeletal System Adaptations
➔Joints return to pre-pregnancy state◆few weeks postpartum➔Feet may increase in size and will not go back to normalEndocrine System Adaptations➔Decreased estrogen levels lead to breast engorgement and diuresis ➔Progesterone decreases and reestablished with the first menses➔Prolactin is secreted and is involved with lactation Breastfeeding➔Breaks milk appears 4-5 days after birth➔Skin to skin contact during first hour after birth is GOLD STANDARD to initiation breastfeeding ***◆helps regulate blood sugars◆respiratory rate◆increase moms oxytocin which helps uterus deflatedecrease moms risk for postpartum sadnessMood disorders(SATA)●Teaching about Postpartum Blues-***○Emotional lability: crying, irritability, anxiety, confusion, sleep disorders (linkedwith hormones, start at end of pregnancy to prepare the body that you won't be sleeping after giving birth)○Peak at 4-5 days postpartum and resolve by day 10○Should seek further evaluation if symptoms last longer than 2 weeks postpartum.○Be aware that people may not feel comfortable seeking helpNursing assessment in the postpartum period***Postpartum assessment- Vital signs, fundal check, assess mom and baby➔During the first hour; EVERY 15 MINUTES➔During the second hour; EVERY 30 MINUTES➔During the first 24 hours; EVERY 4 HOURS➔After 24 hours; EVERY 8 HOURSPost 8 hrs should assess how often???Promoting comfort➔Application of cold and heat***◆Ice pack to relieve discomfort from edema, episiotomy, or laceration by minimizing edema, inflammation, reduce nerve conduction to site
◆Used for first 24 hours, applied intermittently◆Peribottle filled with warm water used to promote comfort and hygiene (after using bathroom, pat dry)◆Sitz bath can be done after 24 hours to promote comfort for episiotomy, perineal trauma, or inflamed hemorrhoids➔Providing Pain Relief◆Hemorrhoids- (SATA)●Apply witch hazel pads, suggest sitz bath, promote increased fluid intake ◆Promoting parental rolesencourage parents to participate in routine newborn care➔Nursing interventions:◆provide lots of opportunities for parents to interact with the newborn➔Convection:◆involve the flow of heat from the body surface to cooler surrounding air or air circulating over a body surface●ex: cool breeze, cool room/corridors or outside air currents◆to prevent heat loss keep the newborn out of direct cool drafts●open doors, windows, fans◆using clothes and blankets in isolettes to reduce the exposure ◆Work inside isolette as much as possible●EX: heat loss from cool breeze from cool room, cool corridors, outside air currents.➔Meconium-First bowel movement following birth◆Composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood◆Greenish black, tarry consistency◆Passed within 12-24 hours after birth➔Development of a mucosal barrier to prevent the penetration of harmful substances◆capacity of the stomach is less than anatomic capacity◆cardiac sphincter and nervous control of stomach are immature●leads to regurgitation and uncoordinated peristaltic activityNeurologic system adaptations➔Congenital Reflexes●Major reflexes:○gag, Babinski. Moro and Galant➔acute senses of hearing, smell, taste, touch, and vision◆reflexes: indication of neurologic development and function APGAR scoring○A = activity (muscle tone)
Nursing interventions➔Maintaining airway patency - PRIORITY AFTER DELIVERY➔Assessment Findings-◆Acrocyanosis-●persistent cyanosis of fingers, toes, and feed●Normal in first few weeks of life●In response to cold exposure◆Caput succedaneum●Swelling will dissipate in 3 days without treatment◆Clavicle Fractures-●Major risk factors○vacuum assisted births and large newborn birth weightNursing Management during the early newborn period➔Skin◆protective barrier between body and environment◆functions: limit loss of water, prevents absorption of harmful agents, protects thermoregulation and fat storage, protects against physical trauma ●accelerated epidermal development with exposure to air for all newborns●Promoting sleep-Avoid unsafe conditions: NO STUFFED ANIMALS IN BEDFirm sleep surface, free from soft objects, toys, blankets,Common concerns: physiologic jaundice, hypoglycemia➔Hypoglycemia-◆Maternal glucose source ◆S/S-Jitteriness, lethargy,Feeding the newborn➔Bottle Feeding (SATA)◆Every 3-4 hours◆Newborns need 100-110 cal/kg or 650 cal/day➔Breastfeeding is on demand, or about 2-3 hours**➔Bottle/formula fed should be every 3-4 hours**➔Adequate intake: growth, 6-10 wet diapers/day, satiated after feeds**➔Burp frequently**Discharge Preparation (SATA)➔Ensure follow up care
➔Hunger cue signs➔Encourage using community for assistance and support➔When to contact medical provider: signs of infection, hemorrhage, depression, DVT/PEs,poor feeds/latch, increase in pain and/or bleeding, headaches unrelieved with medication (fever???)