1
Uncomplicated Labor and Delivery
Lecture 4
I.
Physiological effects of the birth process
A.
Maternal response
1.
CV
a.
During U/C-300-500 ml blood from uterus to vascular
system
b.
Increase in cardiac output
10-15% Stage I
30-50% Stage II
c.
Blood pressure changes
1.
blood flow ↓ in the uterine artery
during contractions and is redirected to the
peripheral vessels
2.
peripheral resistance occurs with an
↑ in BP and ↓ of pulse
3.
Stage I- ↑ 30 mm Hg systolic
↑ 25 mm Hg diastolic
4.
Stage II-↑ BP further
5.
Supine hypotension-risk factors
multifetal, hydramnios, obesity,
dehydration, hypovolemia
d.
WBC’s  25-30,000 mm secondary to stress,
trauma
e.
hematopoietic
1.
desire Hgb at least 11 g/dl
Hct 33% or higher
2.
↑ plasma fibrinogen→ ↓ blood coag
time→ ↑ clotting factors to protect
against hemorrhage but ↑ risk for
thrombophlebitis (inflammation of
vein in conjunction with formation
of a thrombus (blood clot of a vessel
or a cavity in the heart)
2.
Fluids/electrolytes
a.
Diaphoresis, ↑ insensible water loss through
respirations, NPO status, and ↑ temp
b.
Voiding may be difficult r/t anesthesia or
Pressure from presenting part-↓ sensation of a full
bladder
c.
Proteinuria-↑ in amino acids may exceed capacity of renal
tubules to absorb
-may be renal damage caused by vasospasms of
tubules
2
3.
GI
a.
b.
B.
Fluids at tolerated r/t ↓ GI motility and
absorption with delay in stomach
emptying
N & V with diarrhea in labor
4.
Respiratory
a.
↑ O2 consumption, ↑ in resp. rate
b.
hyperventilation →respiratory alkalosis
↑ in pH, hypoxia, hypocapnia (↓CO2)
c.
2nd Stage-O2 consumption ↑ → metabolic
acidosis uncompensated by resp. alkalosis
5.
Muscular/skeletal
a.
Fatigue of muscles/strain
b.
Separation of pubis symphysis
-May be related to pregnancy or
delivery process
(relaxin-polypeptide hormone-secreted
in corpus luteum during pregnancy-can
relax the symphysis, inhibit uterine
contractions, and softens the cervix)
c.
Breakdown of proteins may lead to
proteinuria-albumnin in the urine
6.
Neurological
a.
Euphoria-believe it or not!
endorphins-↑ pain threshold and produce
sedation
b.
↑ anxiety
c.
partial to total amnesia in 2nd stage
7.
Integumentary
a.
diaphoresis
b.
↑ temperature-may be R/T to maternal
efforts or infection
c.
exacerbation of pruritusmay be related to cholestasis (arrest of the flow of
bile) in pregnancy
Fetal Response
1.
CV
a.
∆ in fetal heart rate (FHR)
-maternal hydration
N&V
↑ maternal temp
insensible water loss
-maternal position
3
-medications to mother
-placental issues
post dates-calcifications
smoker/↑ BP-↓ placental size
velamentous insertion (umbilical
cord attached to the membrane a short
distance from the placenta
cord compresson
-maternal anxiety
II.
2.
Pulmonary
a.
thoracic cavity squeezed
-not as much in C/S cases
-precipitous deliveries (swift progression of
2nd stage of labor marked by rapid
descent/expulsion of the fetus)
-may need extra suction
b.
passing of meconium (1st feces of
neonate) may need resuscitation effort
3.
Catecholamines
a.
epinephrine & norepinephrine-active
amines (nitrogen-containing organic
compounds)
-have effect on CV, neuro, metabolic
rate, temp., and smooth muscle
b.
change R/T ↑ stress of labor
speed clearance of fluid
Essential Components of the Birth Process
A.
Passageway
1.
maternal pelvis
a.
4 bones
-2 innominate (nameless) bones
-made up of 3 bones
-ilium-iliac crest
-ischium-ischial tuberosity
-spines-shortest diameter
-pubis-symphysis pubis
-the sacrum
-the coccyx
b.
False pelvis-the upper pelvis
-portion above the inlet
c.
True pelvis
-inlet
-diagonal conjugate-lower border
of symphysis pubis-sacral
promontory
4
-usually 12.5 cm or greater
-obstetric conjugate- also called
anterior/posterior diameter
-measurement that determines
whether presenting part can
engage superior strait
-usually 1.5-2 cm less than
diagonal
-midpelvis-cavity, midplane
-transverse diameter-interspinous
diameter-10.5 cm
-outlet
-transverse diameter-intertuberous
diameter-> 8 cm
2.
B.
Pelvic shapes
a.
gynecoid-round
-50% of women
-most favorable
-usual mode of birth-vaginal
b.
android-heart shaped
-23% of women
-usual mode of birth-cesarean
possible forceps-difficult
c.
anthropoid-oval shaped
-24% of women
-usual mode of birth-vaginal
spontaneous or asst.
-may lead to OP position
d.
platypelloid-flat shaped
-3% of women
-not favorable for vaginal delivery
Passenger
1.
Fetal skull
a.
made up of 6 bones
-frontal
-2 parietal
-2 temporal
-occipital
b.
not fused together-allow for molding,
overlapping of bones to pass thru pelvis
c.
sutures-membranes
-frontal
-sagittal
-lambdoidal
-coronal
d.
fontanels-where membranes intersect
5
e.
-anterior (bregma)-diamond-shaped-2cm
by 3 cm
-closes by 18 months
-posterior-triangle-shaped-1cm by 2 cm
-closes by 8-12 weeks
landmarks
-mentum-chin
-sinciput-brow
-vertex-between anterior/posterior
fontanel
-occiput-beneath the posterior fontanel
2.
Fetal Presentation
a.
fetal part entering the pelvis first
-cephalic (head)-96%
-breech (buttock)-3%
-transverse (shoulder)-1%
b.
factors that influence presentation
-fetal lie
-fetal attitude
-extension/flexion of fetal head
c.
diagnosed using
-Leopold’s maneuvers
-verify with ultrasound
d.
external version-MD attempts to manually
rotate the fetus into a cephalic
presentation
-done in L &D
-ultrasound to check fetal/placental
position
-may use medications to relax uterine
muscle
-frequently uncomfortable for mother
3.
Fetal Lie
a.
relationship of long axis (spine) of fetus
to long axis (spine) of mother
b.
primary lies:
-longitudinal (vertical)-cephalic, breech
-transverse (horizontal or oblique)-shoulder
4.
Fetal Attitude
a.
relationship of fetal parts to one another
b.
general flexion
-back is rounded
-chin flexed onto chest
-thighs flexed on the abdomen
-legs flexed at the knees
6
c.
C.
-arms crossed over the thorax
-umbilical cord lies between arms/legs
head flexion
-biparietal diameter-9.25 cm
-suboccipitobregmatic-9.5 cm
-occipitofrontal-12 cm
-occipitomental-13.5 cm
5.
Fetal position
a.
relationship of presenting fetal part to
4 quadrants of maternal pelvis
b.
indicated using a 3-letter abbreviation
-1st letter-location of part in pelvis (R or L)
-2nd letter-presenting part of fetus (O,S,M)
-3rd letter-location of presenting part in
relationship to maternal pelvis (A,P,T)
6.
Station
a.
relationship of presenting fetal part to an
imaginary line at the maternal ischial
spines: 0 station is at the spines
b.
negative stations-higher in the pelvis
c.
positive stations-lower in the pelvis
Powers
1.
Primary Powers
a.
involuntary uterine contractions
-start at fundus-thickened uterine
muscle layer of upper uterine
segment
-upper segment thicker so more active
-lower segment has less muscle
-contractions move down muscle
in waves
-assessed by:
reports from mother
RN palpating fundus
monitor
b.
primarily responsible for dilation of
cx and descent of fetus
-drawing upward of the
musculofibrous components
of the cervix with fetal head compression
lead to dilation (opening)
-full dilation (10 cm) marks the end of
the first stage of labor
c.
effacement (thinning)
-cx usually 3 cm long, 1 cm thick
7
d.
e.
2.
D.
-taken up by shortening of uterine
muscle bundles
-usually expressed in %
uterine contractions
-3 phases-increment, acme, decrement
-involuntary, rhythmic, intermittent
-frequency-beginning of one to the
beginning of the next
-regularity-usually start irregular then
becomes more regular as labor progresses
-duration-start to end of contraction
-intensity-mild, moderate, strong or
strength can be measured with
internal monitor (IUPC) with
resting tone usually 15-25 mm
Ferguson’s reflex
-presenting fetal part reaches perineal
floor
-mechanical stretching of cervix occurs
-stretch receptors in vagina trigger
exogenous (originating outside an
organ) oxytocin release
-triggers maternal urge to bear down
Secondary Powers
a.
bearing down effort at 10 cm
-contraction of diaphragm and
abdominal muscles while pushing
b.
↑ intraabdominal pressure that
compresses uterus on all sides
c.
usually no effect on dilation-important
R/T expulsion of fetus and placenta
d.
better results when await maternal need
to bear down rather than start pushing
at 10 cm
e.
debate over how to push
-valsalva-closed glottis, prolonged push
-open glottis pushing
-mini pushes
f.
prolonged pushing efforts can lead to
fetal hypoxia/acidosis and severe maternal perineal
lacerations
Placenta
1.
Structure
a.
formed at implantation
b.
decidua (endometrium during
pregnancy) basalis-with the chorion
8
c.
d.
e.
f.
g.
2.
(extraembryonic membrane) forms the placenta
cotyledon-mass of villi on the chorionic
surface of the placenta
-15-20 in number
structure is completed by 12 week
breaks may occur in placental
membrane allowing mixing of maternal
and fetal blood-Rh sensitization
position problems
-previa-implanted in lower uterine
segment-covers internal cx os
-abruptio-separation of placenta from
uterine wall
-accreta-cotyledons invaded uterine
musculature
-increta-invasion into the myometrium
-percreta-invasion to the serosa of the
peritoneum covering of the uterus
can lead to uterine rupture
umbilical cord insertion problems-pg. 482
-battledore-insertion into the margin of the
placenta-resembles a paddle
-velamentous-attached to membrane a
short distance to placenta
Function
a.
endocrine gland-produces hormones to
maintain pregnancy
-hCG-human chorionic gonadotropin
-basis for pregnancy test
-preserves function of corpus luteum
-ensures continued supply of
estrogen/progesterone
-reaches max level at 50-70 days
-hPL-human placental lactogen
-similar to growth hormone
-stimulates maternal metabolism
-↑ resistance to insulin and facilitates
glucose transport across
placental membrane (GDM?)
-estrogen (estriol)
-stimulates uterine growth
-stimulates uteroplacental blood
flow
-progesterone
-maintains endometrium
-decreases contractility of uterus
-stimulates development of breast
9
b.
c.
E.
Psyche
1.
Factors influencing woman’s reaction to
physical/emotional crisis of labor
a.
accomplishment of tasks of pregnancy
b.
usual coping mechanisms in response to stress
c.
support system-esp. partner’s commitment
d.
preparation for childbirth
e.
cultural/religious influences
f.
social/economic responsibility
2.
F.
III.
alveoli and maternal
metabolism
metabolic functions
-respiration
-nutrition
-excretion
-storage
factors which could effect function
-smoking
-drug use
-poor nutrition
-↑ BP
-maternal position
-infection
-trauma
Factors associated with birth experience
a.
motivation for pregnancy
b.
attendance at childbirth classes
c.
sense of competency/mastery
d.
self-confidence/self-esteem
e.
+ relationship with partner
f.
maintaining control during labor
g.
support during the delivery
h.
not being left alone
i.
trust in staff-medical and nursing
j.
pain management
k.
length of labor process-exhaustion, ↑ anxiety, ↑ for
medical interventions
Position (maternal)-See book
Labor Physiology
A.
Labor Onset Theories
1.
Oxytocin Stimulation Theory
a.
stretching of cervical os causes ↑ in
exogenous oxytocin
b.
produced by posterior pituitary
10
c.
d.
B.
oxytocin stimulates smooth uterine muscle
contractions
↑ response to oxytocin as nears term
2.
Estrogen Stimulation Theory
a.
estrogen stimulates smooth uterine muscle
to contract
b.
as approaches term, ↑ estrogen,
↓ progesterone (prog. keeps estrogen in check)
c.
promotes prostaglandin synthesis (also
stimulates muscle)
3.
Progesterone Withdrawal Theory
a.
usually relaxes muscle
b.
at term-↓ in effectiveness
4.
Fetal Cortisol Theory
a.
at term, fetus produces more cortisol
b.
cortisol-(adrenocorticcal hormone)
-slows production of progesterone
-stimulates prostaglandin precursors
5.
Uterine Distention Theory
a.
stretching uterine muscles causes
irritability leading to contractions
b.
stimulates production of prostaglandins
6.
Prostaglandins
a.
stimulate smooth muscle to contract
b.
can have production stimulated by
various methods
-↑ synthesis of PGE2 in amnion
c.
research varies whether concentration
of prostaglandins ↑ in amniotic fluid and
maternal blood just before labor onset
Signs of Labor
1.
Braxton-Hicks contractions
a.
4-6 weeks before onset of labor
b.
uterine muscle workout before labor
c.
may be strong and frequent but usually
are irregular in pattern
2.
Lightening
a.
fetal descent into the true pelvis
b.
2-3 weeks in primigravidas
closer to onset of labor in multiparas
c.
easier to breathe, ↑ need to void
11
3.
Cervical and vaginal changes
a.
cervix ripens (softens) and may begin to
dilate and efface
b.
vaginal mucus ↑ with mucus plug being
released 1hr, 1day, or even 1 week before start of
labor
c.
occasionally bloody show noted with
dark brown or light pink-tinged mucus noted
4.
Persistent low back ache
a.
R/T relaxation of pelvic joint and descent
of fetus
b.
change of position, warm packs, and
warm showers/baths help
Weight Loss
a.
R/T GI upset with N & V and diarrhea
b.
usually starts 1-2 days before onset
5.
6.
C.
Nesting
a.
have a burst of energy
b.
have a need to get everything in order
for arrival of baby
True vs. False Labor
True
False
Uterine contractions
regular
irregular
close together
vary
stronger
milder
↑ with walking
↓ with walking
felt in low back then
radiates to abdomen
felt in back or pelvis
not stopped by bath
or fluid
↓ with relaxation
techniques
Cervix
softens, effaces, dilates
no significant changes
Fetus
starts descent into pelvis
no change in position
12
D.
E.
Effacement, dilation, and station
1.
Effacement
a.
thinning of cervix (shortening from usual
length of 2-3 cm)
b.
documented either in %’s or cm’s
2.
Dilatation
a.
opening of cervical os from closed to
10 cm
b.
due to retraction of cervix into the lower
uterine segment R/T uterine contractions and pressure
from amniotic sac and fetus
c.
both dilation and effacement are
measured by fingertip palpation or visual
inspection with sterile speculum
3.
Station
a.
using imaginary line at ischial spines, note location
of presenting fetal part
b.
documented from –4 to +4
c.
ballottable-when presenting part is floating in and
out of the pelvis
Stages and Phases of Labor
1.
Prodromal phase
a.
strong regular contractions without
cervical change
b.
leads to exhaustion R/t inability to sleep
c.
may need oral/IM medication for rest
2.
Stage 1 (0-10 cm)-has 3 phases
a.
Early/Latent phase-0-3 cm, 50-90%, -3to -1
-able to walk and talk
-able to eat light meals
-may be home for most of this phase
-involves more cx effacement and less
change in fetal position
-U/C’s may be 2-10 minutes apart
-U/C’s mild by palpation
-lasts an average 8 hours for primips
-multiparas may have cx dilate to 3 cm
days prior to onset of labor
-ROM may occur during this time
b.
Active phase-4cm-7cm, 80-100%, -2 to 0
-U/C’s every 3-5 minutes, moderate by
palpation
-U/C’s last approx 60 sec
-may start to have nausea/vomiting
13
c.
F.
-may ask for enema if impacted to
speed descent of fetus
-may ask for pain medications
-provider may decide to AROM to help
speed labor
-expect cx to change 1cm every 1-1.5 hrs
Transition phase-8-10 cm, 100%, -1 to +1
-U/C’s every 1-3 minutes with ↑ intensity
-U/C’s last 45-90 sec long
-using breathing techniques not to push
too early
-may ask for more pain medication
-shortest phase-usually 15 min-3 hours with
delays R/T medications/infections
3.
Stage 2-10 cm (pushing) to delivery of neonate
a.
nulliparas-2 hours on average-no epid.
3-4 hours with epidural
b.
multiparas-15 min-1 hour without epid.
1-2 hours with epidural
4.
Stage 3-birth of neonate to expulsion of
Placenta
a.
usually lasts 20 minutes to 1 hour
b.
if retained, MD will need to manually
remove-consider pain meds for mom
5.
Stage 4-Recovery
a.
mom-1-4 hours
b.
baby-6 hours
Mechanisms of Labor (Cardinal Movements)
1.
Engagement and Descent-occurs r/t:
a.
pressure of amniotic fluid
b.
uterine pressure on the breech
c.
contractions of abdominal muscles
d.
extension/straightening of fetus
2.
Flexion
a.
natural attitude of fetus
b.
fetal head flexes as it meets
resistance
3.
Internal Rotation
a.
to go thru transverse diameter
b.
rotates to occiput anterior
14
G.
4.
Extension
a.
resistance of pelvic floor with vulva
opening forward and anterior
b.
fetal head begins to crown
5.
External Rotation
a.
shoulders rotate to anteroposterior
b.
fetal head rotates further to one side
6.
Expulsion
a.
anterior shoulder slips under
symphysis pubis
b.
posterior shoulder and body is then
delivered
Labor Duration
1.
Nulliparas
a.
1st stage-13 hours (1.2 cm/hr)
b.
2nd stage-5 minutes-2 hours
c.
3rd stage-10-20 minutes
2.
IV.
Primi/multiparas
a.
1st stage-7 hours (1.5 cm/hr)
b.
2nd stage-5 minutes to 1 hour
c.
3rd stage-5-20 minutes
Plan of Care
A.
Assessment-Data Collection
1.
prenatal record
a.
assess attendance to PN appts
b.
any complications of pregnancy
c.
any high risk behaviors
d.
abnormal lab/ultrasound reports
1.
blood type/RH factor
2.
VDRL/RPR-syphilis screen
3.
HbsAG-surface antigen
4.
CBC
5.
Rubella immunity
6.
culture for GBS
7.
urinalysis
8.
HIV test
e.
primary language
2.
initial interview
a.
ask why she came in
b.
status of BOW
c.
any U/C’s?
d.
any bleeding?
15
e.
f.
B.
+ FM recently?
any other symptoms?
3.
physical exam
a.
maternal vital signs
b.
FHR tracing
c.
palpate strength of U/C’s
d.
assess fetal presentation
e.
assess cervical dilation/effacement
4.
lab reports/ultrasound results
a.
CBC
b.
PIH panel
c.
RBS (sure step or lab draw)
d.
ck fetal lie/AFI with ultrasound
5.
expressed psychosocial and cultural
factors/needs
a.
history of sexual/physical abuse
b.
history of depression/suicide attempts
c.
social support
-family near by
-friends who can pitch in
d.
cultural/religious needs
6.
clinical evaluation of labor status
a.
sign consent forms
b.
CBC and urine test
c.
if ROM, ck nitrazine paper or ferning
d.
Leopold’s maneuver
e.
vaginal exam
f.
ultrasound if needed
g.
head to toe assessment
h.
ck for med allergies
i.
ask about classes taken
Nursing Diagnoses
1.
Anxiety R/T labor and birthing process
a.
orient parents to unit
b.
explain admission protocol
c.
assess woman’s knowledge,
experiences, and expectations of
labor
d.
discuss progress of labor
e.
involve woman and partner in care
decisions during labor
2.
Pain R/T increasing frequency and intensity of
16
contractions
a.
assess level of pain
b.
encourage support people to aid in comfort
measures
c.
encourage use of relaxation techniques
d.
explain when and why analgesics may be used
C.
3.
Risk for altered pattern of urinary elimination R/T
sensory impairment secondary to labor
a.
palpate the bladder superior to symphysis
b.
encourage frequent voiding
c.
assist to BRP or use catheter prn
4.
Risk for fluid volume deficit R/T ↓ fluid intake
and blood loss during birth
a.
monitor fluid loss
b.
administer oral/parenteral fluid prn
c.
monitor fundus for firmness
d.
administer medications to aid in
contraction of uterus
e.
possible type and screen/cross match
if transfusion needed
5.
Impaired gas exchange R/T maternal ↓ BP,
compression of umbilical cord
a.
keep mother off her back
b.
maintain adequate hydration
c.
oxygen via mask if O2 below 90%
d.
shut off pitocin
e.
possible need for amnioinfusion
Interventions-Priority Setting
1.
Vital signs
a.
notify provider if BP above 140/90
b.
ck temp q 4 hrs if ROM
2.
Fetal monitoring
a.
assess FHR at least once hourly in
early phases
b.
may need continuous monitoring
c.
consider internal monitoring for poor
tracing, lack of progress, or meconium
3.
Hydration/oxygenation
a.
encourage po fluids or start IV if N & V
b.
ck oxygen saturation if decels noted
4.
Comfort measures
17
a.
b.
c.
d.
breathing/focal points/distractions
-labor shakes are normal
hydrotherapy/massage
active listening R/T maternal behaviors
-0-3 cm: anticipation, excitement
-4-7 cm: seriousness, introspection
-8-10 cm: irritable, fatigue, amnesia
use of support people
5.
Pain management
a.
showers/warm or cool packs
b.
massage
c.
oral medications
d.
IV or IM medications
e.
Epidurals
6.
2nd stage interventions
a.
room prepped for delivery
-warmer for neonate
-delee suction if meconium present
-possible need for Pedi
-keep up NRP/BLS skills
b.
asst mother with a variety of positions
while pushing
-short pushes 6-7 seconds
-consider open-glottis pushing
-squatting can open the pelvis an
addition ¼ inch
c.
assess need for addition oxygen R/T FHR
tracing
d.
assess maternal VS and FHR tracings per
hospital policies
e.
keep Provider aware of pt’s progress
f.
consider lessening epidural dose if
pushing effort less than adequate
g.
provider should be in LDR before head is
crowning to provide support for perineum
h.
clean perineum if requests by provider
i.
at delivery, asst partner with cutting of
umbilical cord
7.
3rd and 4th stage interventions
a.
asst provider with lidocaine/suture if
perineal/vaginal repair is needed
-episiotomies: median or mediolateral
-lacerations:
1st degree-skin, superficial
2nd degree-muscles of perineum
18
b.
c.
d.
e.
f.
g.
V.
3rd degree-to anal sphincter muscle
4th degree-anterior rectal wall
fundal rub post delivery of placenta
-watch for trickle/spurt of blood and
change in uterine shape to herald
expulsion of placenta
observe for need for pitocin/methergine
promote bonding/breastfeeding even
during repair
ice pack to peri/VS q 15 min/pain meds
prepare for possible trip to OR if placenta
is retained (↑ 1 hr)
immediate newborn care
-dry off fluids, skin to skin, suction mucus
-ck for 3-vessel cord
-ck physical assessment/wt./length
-APGAR score and infant ID tags
Obstetrical Instrumentation and Procedures
A.
Amniotomy-AROM (artificial rupture of membranes)
1.
most frequently used method of labor induction
B.
2.
induces labor when cervix is favorable or augments
a slowing labor progress
3.
labor usually begins 12 hours post rupture-if prolonged,
can lead to infection-Ck temp q 2 hours
4.
can be used in combination with oxytocin
5.
explain to pt that procedure is painless but might feel
increase in vaginal pain R/T movement of fetus
6.
presenting fetal part must be engaged in pelvis and
applied to cervix to prevent cord prolapse
1.
assess color, odor, consistency and quantity of fluid
Induction and augmentation of labor
1.
chemical agents
a.
PG gel-prostaglandin gel
Cervidil/Prepidil/Prostin E2-dinoprostone
-helps to ripen (soften and thin) cervix
-may initiate labor without further medications
-may be used to terminate pregnancy
-adverse reactions
headaches, N & V, diarrhea, fever
hypotension, hyperstimulation of uterus
19
fetal passage of meconium
b.
c.
d.
e.
f.
2.
C.
Cytotec (misoprostol)-synthetic prostaglandin E1
-not FDA approved for cervical ripening
oxytocin
-hormone produced by posterior pituitary gland
-stimulates uterine contractions
-used to induce or augment labor
-indications for use
suspected fetal jeopardy
dystocia
postdates
maternal medical problems
fetal demise
-contraindications for use
CPD, cord prolapse, transverse lie
nonreassuring FHR
placenta previa or vasa previa
classical uterine incision
active genital herpes
invasive CA of the cx
infusion done on IV pump
watch for tachysystole
assess fetal well-being and maternal pain level
mechanical methods
a.
dilators
b.
amniotomy
Version
1.
external
a.
attempt to rotate fetus from a malpresentation
b.
usually done at or after 37 weeks
c.
U/S scanning before to ck fetus and placenta
d.
may use a tocolytic agent like terbutaline
e.
obtain informed consent-usually done in L & D
due to risk of complications
f.
MD or CNM give gentle, constant pressure to
abdomen to rotate presenting fetal part
g.
Rh – moms may receive Rhogam due to the risk
of fetomaternal bleeding
2.
internal
a.
MD inserts hand into the uterus and changes
position or presentation
b.
may be used in multifetal pregnancies to rotate
second fetus
c.
maternal/fetal injury possible
20
d.
D.
E.
RN role to monitor FHR and support mother
Episiotomy
1.
incision in the perineum to enlarge the vaginal outlet
2.
types
a.
median-midline
-most commonly used
-effective, easily repaired
-can possibly extend into rectum
b.
mediolateral
-prevents 4th degree laceration
-repair most difficult
-more pain to mom
3.
pros
prevents tearing
decreases stage 2
enlarges vagina
4.
less rate of episiotomies with CNM vs. MD
cons
lacerations can occur
↑ pain/discomfort
lateral position can
control head
Forceps
1.
uses paired curved blades to asst. delivery of head
2.
maternal indications for use
a.
second stage arrest
b.
cardiac moms
c.
poor pushing effort/fatigue/anesthesia
3.
fetal indications for use
a.
distress
b.
abnormal presentation-asynclitic
c.
delivery of head during breech delivery
4.
conditions
a.
fully dilated
b.
empty bladder
c.
engaged presenting fetal part
d.
vertex
e.
ROM
f.
No CPD
5.
care management
a.
assess FHR before and after delivery
b.
Pedi MD at delivery
c.
assess mother for lacerations, urinary retention
21
d.
F.
G.
assess baby for facial bruising, abrasions, palsy
Vacuum
1.
attachment of vacuum cup and use of negative
pressure
2.
indications/conditions the same as use of forceps
3.
follow hospital’s P & P R/T method, suction pressure,
duration, and charting
4.
newborns-ck for caput, cephalohematoma, scalp
laceration
Surgical Birth
1.
birth of the fetus thru a transabdominal incision in the
uterus
2.
term cesarean from Latin “caedo”-to cut
3.
C/S rate-20-30%-higher in women over the age of 35
4.
↑ rate of VBAC’s had lead to ↓ C/S’s but might Δ
5.
purpose to preserve health or life of mom or baby
6.
↑ in C/S rate R/T
a.
increased EFM
b.
epidural use
d.
↑ of repeat C/S
e.
AMA moms
f.
private insurance/private hospitals
g.
moms with high SES
1.
indications for C/S
a.
fetal distress/intolerance of labor
b.
CPD/malpresentation/malposition
c.
placental abnormalities
d.
umbilical cord prolapse
e.
dysfunctional labor pattern/first stage arrest
f.
multiple gestation
g.
active genital herpes
h.
uncontrolled HTN
i.
PIH/preeclampsia
2.
type of incisions
a.
skin-vertical or horizontal (Pfannenstiel, bikini)
b.
uterus-vertical (classical), low vertical, and
22
horizontal (low transverse)
-classical-faster to perform, is performed in other
countries, contraindication for VBAC
-transverse-easier, less blood loss, decrease risk
for infections, less likely to rupture, may
attempt VBAC with next pregnancy
3.
risks/complications
a.
aspiration
b.
pulmonary embolism
c.
wound infection
d.
wound dehiscence
e.
thrombophlebitis
f.
hemorrhage
g.
UTI
h.
injury to bladder or bowel or fetus
i.
anesthesia complications
j.
decreased satisfaction with the birth process
k.
loss of ability to accomplish vaginal deliveries
l.
increase financial expense
m.
longer hospital stay
n.
bonding and breastfeeding may be delayed
4.
types of anesthesia
a.
regional blocks
-epidural-most common, feel pressure, no pain
-spinal-no pain or pressure
b.
general
-higher risk of complications
11.
pre & intraoperative care-pg. 510-512
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