Prework Week 2
Week 2 Pre Work Assignment
Chapter 8-Prework
Labor triggers
Maternal triggers
-Uterine muscles stretch to threshold 
Prostaglandin/oxytocin release  contractions.
-Increased cervix pressure stims. nerve plexus to
release oxytocin from pituitary  contractions.
-Increased estrogen increases uterine response.
-Progesterone relaxes lower, estrogen takes over.
-Oxytocin stims. myometrial contractions, works w/
prostaglandins to inhibit calcium muscle binding.
(Calcium increases = more contractions).
-Oxytocin surges due to cervix stretching.
Fetal triggers
-Aging placenta  deterioration 
contractions.
-Prostaglandin synthesis by membranes and
decidua  contractions.
-Fetal cortisol from adrenal glands rises and
stims. placenta to reduce progesterone
production  MORE contractions.
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5 P’s of Labor List and explain
Power
Passenger
Position
POWER
The involuntary
contractions of labor and
voluntary pushing/beardown.
Upper segment pushes
fetus down, lower segment
thins out and pulls up.
-Dilates and effaces.
Contractions reduce blood
supply and needs resting
period to allow O2 to
replenish.
-Frequency (mins)
-Duration (secs)
-Intensity (palpated)
-Mild, moderate, strong
 indentation.
Phases:
-Increment: builds up
from fundus to body
(longest phase).
-Acme: peak of intensity
(short).
-Decrement: descending
and relaxation.
Ferguson Reflex: urge to
push due to pelvic flood
muscle stretch  oxytocin
and contractions stim.
Passageway
Psyche
PASSENGER
PASSAGE
POSITION
Affected by fetal
skull, attitude, lie,
presentation, position,
and size.
-Skull: 2 parietal, 2
temporal, frontal, and
occipital bone 
molds to fit through
canal.
 ID anterior
fontanel to
determine
head position
and rotation.
-Attitude
flexion/extension:
term babies have
convex back, head
flex, chin to chest.
-Lie: long fetal axis to
long maternal spine
axis.
 Longitudinal
(parallel) or
transverse
(perpendicular
and need CS).
-Presentation: pole of
fetus enters pelvis first
 cephalic head,
breech, or shoulder.
Includes bony
pelvis and soft
tissues of cervix,
pelvic floor, vagina,
and introitus.
 Assess
pelvis for
vag.
Delivery
through
palpation.
6 positions:
-Right anterior,
transverse, posterior.
-Left anterior,
transverse, posterior.
Types of bony
pelvis:
-Gynecoid
(common)
-Android (heart)
-Anthropoid
-Platypelloid (least
common)
Divided into false
(shallow upper) and
true (lower w/ 3
planes: inlet,
midpelvis, outlet 
obstetric cap.
Pelvic joints:
symphosis pubis,
R/L sacroiliac
joints, and
sacrococcygeal.
-Occiput: cephalic
-Sacrum: breech
-Acromion: shoulder
-Mentum: face
Position in 3 letters:
-1st  location of
presenting part
-R/L
-2nd  fetal part
presenting
-O/S/M/A
-3rd  relationship of
fetal part to mom’s
pelvis
-A/P/T
Maternal: freedom of
movement to help w/
pain.
- 1st Stage: walk, sit,
kneel, squat  aids
descent, reduces
supine HOTN,
shorter labor,
decrease med needs.
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PSYCHE
Culture: includes
birth traditions.
-Who is w/ them
during labor?
-Pain
-Who cares for
mom?
-Labor response.
Expectation:
-How is childbirth
perceived by
woman?
-Past experiences
(may raise anxiety).
Support System:
-Helps with
decreasing anxiety,
pain, and increasing
control.
-Emotional support,
distracting acts.,
advocate.
Adoptive parents:
know about
relinquishment,
feelings, rights to
birth mother about
experience.
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Consider: push duration,
parity, epidural, push
adequacy, mom/fetal
progress, and woman’s
preferences.
-Presenting part: fetal
structure nearest to
cervix (attitude and
posture determines).
 Cephalic:
head first.
Can have
vertex flexed,
frontum brow
slight
extension,
face,
extension of
mentum.
 Breech:
complete,
Frank,
footling.
 Transverse,
compound.
Estrogen and
relaxin increase soft
cartilage and
increase ligament
elasticity for more
fetal head room.
-2nd Stage: <push>
upright positions help
with pelvic outlet
increase and aligns
fetus.
Lithotomy position =
most common.
Gestational
surrogacy: focus on
surrogate mom.
Labor support:
encourage mobility,
lessen stress,
emotional support.
Station: ischial
spines and present
fetus part  festal
descent.
 Station 0 =
narrowest.
This is
where you
want mom!
 Above
ischial =
neg. Below
ischial =
pos. At line
= 0.
Soft tissues: cervix
efface/dilates to
descend. Pelvic
floor helps ant.
rotate  vag.
expands.

Premonitory Signs of Labor (5) -ATI
o Backache – low dull ache by pelvic muscle relaxation.
o Weight loss of 0.5-1.5 kg.
o Lightening  baby drops lower into pelvis (14 days prior to labor)
 Breathing is easier.
 Increased urinary frequency (more pressure on bladder).
 Especially with primigravida.
o Contractions – starts with Braxton-Hicks and increases in strength and regularity.
o Bloody show
o Loss of mucus plug.
o Nesting
o GI changes  N/V and indigestion
o Cervical ripening: softens, opens, efface, dilates.
o Rupture of membranes (water breaks)
 Labor 24 hours after rupture.
 Prolonged = >24 hours before delivery  risk of infection.
 Assess FHR for decels., distress, and cord prolapse.
o Assess amniotic fluid  clear, watery, slight yellow, no foul odor, 700-1000 mL.
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



Nitrazine paper confirms (alkaline between 6.5-7.5 or blue paper turns
yellow = slightly acidic).
 <500 mL = amnioinfusion.
Mechanisms of Labor/Cardinal movements
o Engagement: presenting part (largest) passes pelvic inlet  Station 0.
o Descent: progress of head, measure in cm.
 Negative – above ischial spine.
 Positive – below ischial spine.
 Station 0 – at ischial spine.
o Flexion: fetal head resistance to cervix, pelvic wall, or floor (head flexion, chin to
chest  smaller diameter passes through).
o Internal rotation: head rotates to lateral anterior position (faces back) <think
corkscrew>.
o Extension: head passes through symphysis pubis  head deflected anterior, chin
away from chest.
o External rotation: restitution  head rotated of back and quarter turn to face
transverse  anterior shoulder passing under symphysis.
o Expulsion: trunk born via flexing towards pubis.
Ferguson’s Reflex: urge to push due to pelvic floor muscle stretching.
o Pitocin secreted  uterine contractions.
Leopold’s maneuver: inspects and palpates abdomen for fetal position, station, and size.
o Determines fetus part at fundus.
o Determines fetal back.
o Determines presenting part.
o Determines head position.
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4 Stages of Labor

Identify and describe the physical changes for each stage.
STAGE 1
Cervical changes: 3
phases – starts w/ true
labor and ends w/ dilation
of 10 cm.
-Latent Phase: excited,
apprehensive, able to relax
and talk through
contractions. (Admitted
only w/ cervical change,
ROM, fetal intolerance of
labor).
 Dilation 0-4 cm.
with 0-40%
effacement, mild
contractions of 3045 sec. every 5-10
min. (like strong
cramps).
-Active Phase: low energy,
internal sensation feeling,
increased discomfort.
 Dilation >6 cm.,
fetal descent,
contractions 45-60
sec. every 2-5 min.
-Transition Phase: irritable,
discouraged, pissed!
 Dilation 8-10 cm.,
contractions 1-1.5
min. every 1-2 min.
 Bloody show,
exhausted, N/V,
difficulty
concentrating, back
pressure, trembling,
sweating, urge to
bear down.
STAGE 2
STAGE 3
STAGE 4
Starts at 10 cm. dilation
and ends with birth of
baby.
After delivery, separation
and expulsion of placenta
and membranes.
Delivery of placenta to 4
hours of stabilization
(Postpartum Period).
2 phases:
-Uterus contracts, decreases
in size, decidual layer
separates (takes a few
minutes to 30 minutes).
-Uterus hardens, umbilical
cord lengthens, gush of blood
from vagina.
Vasoconstriction to
achieve hemostasis.
-Latent Resting: no urge to
bear down.
 Passive descent of
baby.
-Active Descent: intense
contractions, strong urge to
bear down (Ferguson
Reflex).
 Fetus down pelvis
and expelled
through uterus w/
contractions, tissues
stretch.
 Primigravidas – 50
min.
Multigravidas – 20
min. (normal for
hours, but no more
than 4 hours).
 Intense contractions
every 2 min. (60-90
sec.), more bloody
show, flat perineum,
rectum/vag. bulge.
 Closed glottis, direct
pushing,
nondirected, open
glottis  3-4 pushes
for 6-8 secs.
-Use Pitocin, apply traction at
cord, and cord clamping 
decreases PPH, increases
contractions, and expulsion.
BUBBLE-HE and VS
taken at this time.
-Vaginal delivery  blood
loss 500 in 4 hrs.
-C-Section  blood loss
1000 in 4 hrs.
-Examine placenta and cord
after expulsion to make sure
it’s intact.
Fundal massage prevents
hemorrhage.
Golden Hour – pushing 4
hours max.
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Pain management during labor

Pharmacological
o Pain assessment (intensity, location, pattern, distress, pain scale) and preferences.
o Divided into analgesia and anesthesia.
 Analgesia:
 Labor established, provide pain reliefe with minimal risk to
mom/baby.
 Neonatal depression w/in 1 hr before delivery.
 Morphine sulfate  resp. depression (caution @ 2nd stage).
 Butorphanol/Nalbuphine  no res. depression.
o Not for drug dependent.
o Monitor
 Sublimaze  FHR changes, HOTN, CNS depression, resp.
depression.
o Monitor for sedation, N/V, itching, resp. rate and effort.
 Anesthesia:
 Used at time of delivery, episiostomy, or repair.
o Local: perineum/episostomy
 2nd stage of labor or epi/repair  hematoma,
infection risk.
 Monitor for sensation return and swelling at site.
 Regional for L&D (included pudendal block, epidural, and spinal
block).
o Pudendal [nerve]
 2nd stage, vulva anesthetize, lower vagina, perineum
for epi and forcep use.
 Risk for toxicity, hematoma, infection.
 Monitor for return sensation, swelling, infection,
retention.
o Epidural [block]
 Stage 1-2 of labor for vag or C/S births, with
opioids to allow walking.
 Risk for HOTN, N/V, itching, resp. depression,
FHR alterations.
 Regional or general for C/S delivery.
o General (for emergency C/S)
 Fetal depression, uterine relaxation, vomiting,
aspiration.
 Informed consent! NPO, IV large bore, urinary
cath., meds for decreased GI acid, wedge for vena
cava prevention.
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 Non-Pharmacological
o Prepares woman for childbirth, stim. (cutaneous, thermal, or mental), and have
support person.
 Educational classes for birthing process, expectations, and breathing
controls.
 Relaxation and breathing techs (deep breath beginning contraction, slowly
 prevents resp. alkalosis).
 Effleurage: light stroking of abdomen in concentric movement during
contraction.
 Back massage using counterpressure via heel or fist of hand to
relieve internal pressure of head.
 Thermal stimulation: warm or cold packs, showers, baths, numbing cold
for pain relief and release.
 Mental: focal points, imagery, and music.
 Support: SO or doula provided.
o Complementary Therapy
 Aromatherapy
 Lavender, jasmine = relaxation and decreased pain perception.
 Peppermint = decreased nausea.
 Massage relaxes and decreases pain.
 Birthing ball
 Facilitates upright position, pelvis opening, and rolling/bouncing to
manage contractions and pain.
 Hydrotherapy: shower or large tub for endorphin release, muscle tension
decrease, and improved circulation.
 Safe for ruptured membranes.
 Self-hypnosis: reduce pain and decreas need for anesthesia or analgesia.
 Music therapy: calms, decrease stress, diverts attention.
 Acupuncture: improves energy flow, reduce pain/anxiety, labor
progression.
 Sterile water injections
o Dick-Read Method
 Birth w/o fear by education.
 Environmental control
 Relaxation
o Lamaze
 Psychoprophylaxis w/ condition and breathing.
o Bradley
 Husband coaching/support.
 Work with pain and manage.
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Epidural
PREPriority Nursing
Interventions/Assessments
INTRAPriority Nursing
Interventions/Assessments
POSTPriority Nursing
Interventions/Assessments
-Assess pain level.
-Determine knowledge/concerns
about epidural.
-Notify MD and anesthesia about
need.
-Assess baselines:
 BP
 Pulse
 RR
 Temp
 FHR (normal pattern)
-Patient voids prior.
-Order IV bolus to decrease
HOTN risk.
-CBC, platelet count, Rh typing,
screening orders.
-Time out: w/ nurse and anesthesia
to ID, site, and verify procedure.
-Assist anesthesiologist with
epidural placement.
-Patient in lateral position with
head flexed, towards chest or
sitting down, elbows on knees
and feet on stool.
List
List
-Monitor VS every 5-15 min.
(HOTN, RDS)
 SOB might = catheter in
subarachnoid space.
 HOTN <100 mmHg or
20% decrease.
-Lateral/upright position with
uterine displacement to avoid
supine HOTN.
-Assess pain, effectiveness of
meds.
-Assess motor blockade level.
-Monitor for itching.
-Monitor for N/V.
-Monitor for post-op headache
(spinal fluid leakage = notify).
-Monitor urinary retention 
catheter.
Uterine contraction monitoring up
to 1 hr.  side effects  adjust
Pitocin.
-Intravascular injection (maternal
tachy/bradycardia, HTN,
dizziness, tinnitus, metallic taste,
LOC).
 Notify, administer O2,
fluids, meds, CPR.
List
-Obtain consent
-Check lab values (bleeding,
clotting, platelets).
-IV bolus with LR.
-Emergency equipment check
-Time out!
N/A.
-Injection of local anesthetic or
analgesic in epidural space.
-Loss of partial sensation may
occur.
 Monitor, do not manage.
 Dosing is OUT of scope.
 Assess, monitor, and
intervene to minimize
complications.
 Monitor VS, mobility,
LOC, pain, and fetal
status.
-VS every 5 mins., then 15 mins.
after re-bolus.
-Urinary retention catheterization.
-Pain assessment, sensation,
motor.
-Positioning on side.
-Itching, N/V, headache
monitoring.
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 Episiotomy and lacerations
o Episiotomy
 First-degree tear: perineal skin and vaginal membrane.
 Second-degree tear: skin, membrane, and fascia of perineal body.
 Third-degree tear: skin, mucus membrane, perineal body, muscle, and
rectal sphincter.
 Fourth-degree tear: all the way to rectal mucosa and rectum lumen.
o Lacerations
 Can appear in cervix, vagina, or perineum.
 What is the priority nursing actions immediately after delivery of the newborn?
o Unstable – immediately place baby skin-to-skin with mom w/ blanket over. Do
initial assessment from there  facilitates contact.
 Normal vital signs for the newborn:
o HR: 110-160 beats/min.
o RR 30-60 breaths/min.
o BP 65-90/45-65 mmHg (newborns).
o Temp: around 97.8-99.5 F (36.5-37.5 C)
Chapter 9 Pre-work (you may use outline format)
Define:
EFM, FSE, Tocodynamometry/IUPC



Electronic Fetal Monitoring (EFM)
o Fetal assessment based on FHR reflecting oxygenation status.
o Done externally and can measure mom and baby.
Fetal Scalp Electrode (FSE)
o Used with intrauterine pressure catheter (IUPC) when monitoring presenting part
of fetus and contractions of patient when membranes are ruptured.
Tocodynamometry
o Strain gauge used to detect tightness of skin resulting from uterine contractions.
o Placed on area of skin where there is strong smooth contraction is felt.
Amnioinfusion




Option for patients who variable decels. due to lack of amniotic fluid.
o Room temp, LR infused transcervically into IUPC to help cushion umbilical cord
and reduce cord compression.
Bolus usually between 250-500 mL over 20-30 mins. and/or continuous infusion of 120180 mL/hr until 1000 mL is reached.
Contraindications: vaginal bleeding, uterine anomalies, or active infection.
Monitor response of mom and baby, document, avoid iatrogenic polyhydramnios.
Define FHR tracings criteria:
Normal fetal baseline range?
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 Mean FHR rounded to 5 beats/min increments within 10 mins. (excludes accels., decels.,
and variability)  at least 2 mins. of baseline segments.
 110-160 beats/min.
What is variability? And what does it mean?
-Fluctuations in baseline FHR and irregular (change in amplitude and frequency)  important
for predicting adequate fetal oxygenation and fetal reserve during labor.
-Baseline: intact pathway from cerebral cortex  midbrain (medulla oblongata)  vagus nerve
 heart (SNS/PNS)




Absent: No amplitude range detected. BABY LIKELY DEAD.
Minimal: Undetected <5 beats/min range.
o Fetus sleeping, sedated by CNS depressants (opiates, mag. sulfate, CNS injury,
fetal hypoxia, acidosis).
Moderate: Amplitude from peak to trough (6 beats/min to 25 beats/min)  welloxygenated fetus with normal acid-base balance)
Marked: >25 beats/min.
What is an acceleration at term >38 weeks gestation and < 38 weeks gestation.
-Abrupt onset, transient increase with peaks <30 secs.
->32 weeks:

15 beats above baseline and lasts 15 seconds to less than 2 minutes.
-<32 weeks:

10 beats/min or >10 secs.
-Prolonged: 2+ mins., less than 10 mins.


Caused by SNS response to fetal movement.
Transient umbilical vein compression.
What is an early deceleration?
-Apparent, symmetrical, gradual decrease and return of FHR associated with contraction.
-Does not occur early or before contraction.


Nadir = lowest point of deceleration  peak of contraction.
Onset, nadir, recovery mirror contraction.
o Caused by pressure on fetal head that stims. vagal nerve.
o Fetal head compression  increased ICP, decreased cerebral blood flow, decrease
in PO2 with stim. of cerebral chemoreceptor.
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What is a variable? And what does it mean/complications to the fetus
-Abrupt decrease in FHR <30 secs. From baseline to nadir (lowest point)  most common and
can persist over time.


Fetal tolerance comes from variability or accelerations.
If decels. continue to get deeper and last longer, more associated with fetal acidemia 
nadir <60 needs amnioinfusion.
-Decrease in FHR at least 15 beats/min. lasting 15 secs. And less than 2 min. (U, W, V shape) 
accels. First and ends with overshoot decels. (non-acidemia), and alter frequency in 2nd stage of
labor.
-Normal variable decel.: <60 seconds, rapid return to base and variability.
-Abnormal or interminate: prolonged return, persistence <60 beats/min., >60 secs, with
overshoots and tachycardia, and absent variability.

Umbilical cord occlusion, cord compression, umbilical vein compression, umbilical
arteries compression (fetal HTN), prolonged cord compression, sudden descent in late
active phase.
What is a late deceleration and why is it bad for the fetus?
-Symmetrical decrease of FHR with UC  fetal intolerance to labor.
-Gradual onset, nadir lasting at least 30 secs  nadir occurs after peak of contraction.
-Onset, nadir, and recovery of decel.  after UC.
-Nadir decrease 10-20 beats/min.



Due to uteroplacental insufficiency, decrease O2, suppression of fetal myocardium.
W/ minimal/absent variability  hypoxia, fetal acidemia.
W/ HOTEN due to anesthesia, supine, hemorrhage, HTN, placental changes, lack of
HGB or O2 sat, excess uterine contractions.
Normal fetal heart rate? 110-160 beats/min.
Define a bradycardia. FHR baseline of <110 beats/min lasting longer than 10 min.
Labor contractions: What is uterine frequency?
Expressed in mins/secs: # contractions every 10 mins.


Normal = 5 or fewer contractions in 10 mins over 30 min window.
Tachysystole: >5 contractions every 10 mins over 30 min window.
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What is duration of a uterine contraction? Seconds from beginning to end of contraction 
expressed as range.
What are the variables for a Category I.
-Baseline bpm, moderate variability, late/variable decel. not present. Early decel
absent/present, accels. absent/present.
What are the variables for a Category III.
-Absent variability with either recurrent late decels., variable decels.,. bradycardia.
-Sinusoidal pattern.
Identify VEAL/CHOP
Variable decels
Cord compression
Early decels.
Head compression
Accelerations
Okay
Late decels
Placental insufficiency
Medications: Indication, S/E, Contraindications, Mechanism of Action
Terbutaline (Brethine)
-Difficulty breathing for COPD patients.
-Prevents preterm labor.
-May cause changes in breathing, HR.
-Can cause: fatigue, tremoring, increased anxiety, changes in consciousness, allergic reaction.
-Contraindication: hypersensitivity, prolonged delivery (>48-72 hrs).
-MOA: B2 receptors in lungs and uterus stim., causing relaxation, increased breathing capability,
and decreased contractions to decrease chance of delivery.
Procardia (Nifedipine)
-Antihypertensive druge for crises, delays premature labor in women who are not full term.
-Can cause: changes in breathing pattern/effort, may encourage vag. bleeding, chest pain,
changes in consciousness, and may not stop contractions.
-Contraindication: MI, nitrate-containing drug allergies.
-MOA: inhibits Ca+ from entering cardiac and uterine muscle so heart is not overworked and
does not pump as hard. Reduce muscle contractions and promote vasodilation.
Oxytocin (Pitocin)
-Hormone/oxytocic used for controlling postpartum bleeding after placental expulsion, inducing
labor, and possible abortion of premature fetus (<20 weeks).
-Can cause: N/V, changes in heart rhythm, vision, weakness, may cause GI pain, excess
bleeding.
-Contraindication: allergies, excessive uterine contraction dysfunction, not able to deliver
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vaginally (placenta previa, cord around neck, infection), if fetus is in bad positioning, fetal
distress.
-MOA: increase intracellular Ca+ levels and prostaglandins by binding with G-protein receptors
to promote increased uterine contractions.
Methergine (Methylergonovine)
-Stops PP hemorrhaging and manages uterus’ loss of contractions to aid uterus PP return
to normal size.
-Can cause: changes in BP, heart rhythm, and bleeding. Can increase risk for seizures, GI
distress, pain, weakness of muscles, changes in vision.
-Contraindications: allergies, HTN, preeclampsia, currently pregnant (decrease blood supply to
fetus).
Hemabate (Carboprost)
-PP hemorrhages and abortion med. for pregnancies 12-20 wks.
-Can cause: N/V, diarrhea, bleeding, allergic reactions.
-Contraindications: allergies, PID, cardiac disease, renal disease, liver disease, and lung disease.
-MOA: impair blood flow by causing uterine contraction (stops blood flow and expels
developing fetus).
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