N 106
Labor and Delivery
Female external genitals
L&D- the P’s of Labor
• Power
• Passenger
uterine contractions
lie
maternal pushing
attitude
presentation
• Passage
occiput
bony boundaries of pelvis
brow, face
softening of cartilage
shoulder
linking pelvic bones
sacrum
position – LOA,ROP
• Psych
POWER
Uterine muscle layers. Muscle fiber placement.
PASSAGE
Pelvic types: gynecoid, android, anthropoid,
platypelloid
PASSENGER
Typical anteroposterior diameters of the fetal skull.
LIE
• The relationship of
the long axis of the
fetus to the long axis
of the woman
• 99% the lie is
longitudinal and
parallel
• Transverse lie – fetus
is at right angle to
mother
Transverse lie - uncommon
ATTITUDE
Flexion
is normal
flexed
extension
Fetal attitude is the relationship of
fetal body parts to itself.
PRESENTATION
The fetal part that first enters the pelvis
Cephalic Vertex
presentation.
Breech presentation.
Cephalic presentations
Occiput/vertex
Brow
Face
Military
Breech presentations
Full Breech
Frank Breech
Footling Breech
Position
• Fetal position describes the location of a
fixed reference point on the presenting
part in relation to the four quadrants of the
maternal pelvis
• Abbreviations of presenting part is
“cuddled” between maternal pelvis
• LOA, LOP, ROA, ROP, RSA, LMP
• Occiput, Sacrum, Mentum (chin), Anterior,
Posterior
Categories of presentation.
A
B
Quiz
C
D
PSYCHE
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Preparation and information
Anxiety and fear decrease coping
Culture affects views
Both physical and emotional experience
Do not “nurse the machines”
L&D nursing responsibilities
• History
Antepartal
weight gain
fetal gest & growth
risk factors
present status
• Obstetrical
• Medical surgical
• interval
• Assessment
maternal
vital signs
uterine activity
bladder status I&O
bloody show
response to labor
maternal discomfort
fetal
heart rate
Amniotic fluid
L&D Leopold’s maneuvers
• Palpate upper abdomen
• Palpate opposite side in circular motion for
fetal extremities
• Palpate for engagement of presenting part
• Palpate to identify cephalic prominence
What fetal part is in fundus
Palpate for back
Palpate for engagement of presenting part
Palpate position of head –
determine descent & flexion
Location of FHR in relation to the more
commonly seen fetal positions.
Location of FHR in relation to the commonly seen fetal
position
Electronic fetal monitoring by external technique. The
tocodynamometer (“toco”) is placed over the uterine
fundus. The ultrasound device is placed over the area of the
fetal back.
Intrapartum Fetal Assessment
• Fetal Heart Rate
• Electronic Fetal Monitoring
ultrasound transducer
• Response to contractions
tocotransducer
• Internal fetal monitoring – RBOW
fetal scalp electrode
intrauterine pressure catheters (IUPC)
Attached spiral electrode with the guide tube removed.
Characteristics of uterine contractions.
Normal fetal heart rate pattern obtained by
internal monitoring.
Fetal Heart Rate Patterns
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Tachycardia – greater than 160 for 10 min
Bradycardia – less than 110 for 10 min
Absent or minimal beat-to-beat variability
Early decelerations – head compression
Late decelerations – uterine placenta
insufficiency
• Variable decelerations – cord compression
A
B
Comparison of labor patterns. A) Normal uterine contraction
pattern. B) Hypotonic uterine contraction pattern..
Types and characteristics of early, late, and variable
decelerations.
Nursing Interventions for
Decelerations
• Early
• Variable
Continue to observe
Stop oxytocin
• Late
Replace IV fluids
Stop oxytocin
Change mothers position
Replace fluids
Check for prolapsed cord
Change mother’s
Check B/P and Pulse
position
Administer oxygen
Check B/P and Pulse
Notify the physician
Administer oxygen
Prepare to assist with
Notify physician
fetal scalp blood sample
Conditions Associated with Fetal
Compromise
• FHR below 100 or above 160
• Amniotic fluid
Meconium-stained (greenish)
Cloudy, yellowish, or foul-smelling
• Contractions
lasting longer than 90 seconds
occurring less than 2 minutes apart
• Maternal hypotension, hypertension, fever
Actions to increase oxygen to fetus
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If receiving Pitocin stop or slow rate
Reposition mother
Increase non-additive IV fluids
Administer 100% oxygen thru snug face
mask to mother at rate of 8-10 liters/min
• Keep mothers bladder empty
• Change under-pads regularly
L & D true vs false labor
• True labor
contractions:
Start in back & move
wavelike toward
abdomen
Become more intense
with walking
Result in ripening of
cervix, dilation &
effacement
• False labor
contractions:
Noticed primarily in
abdomen
Begin & remain
consistent
Disappear with
walking
No change in cervical
dilation or effacement
To gauge cervical dilatation, the nurse place the index
and middle fingers against the cervix and determines the
size of the opening.
Measuring the station of the fetal head while it is
descending
Mechanism of Labor
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Engagement / Decent
Flexion
Internal rotation
Extension
Restitution
External rotation
Expulsion
Mechanisms of labor.
Stages of Labor
• Stage I
• Stage III
cervical dilation to 10 cm &
birth of baby to
effacement to 100%
delivery of
placenta
early/latent
active
• Stage IV
transition
1-4 hours after
• Stage II
crowning to birth of baby
delivery of
placenta
stabilization
recovery
Phases of Stage I of Labor
• Early/latent - dilates - 0-3 cm contractions
q 5 min X 30-40 sec
• Active - dilates – 4 - 7 cm contractions q 25 min X 40-60 sec
• Transition- dilates – 8-10 cm contractions
q 2-3 min apart X 60-90 sec
Effacement of the cervix in the primigravida. Beginning of labor.
There is no cervical effacement or dilatation. The fetal head is
cushioned by amniotic fluid.
Beginning cervical effacement. As the cervix
begins to efface, more amniotic fluid collects
below the fetal head.
Cervix about one-half effaced and slightly dilated.
The increasing amount of amniotic fluid exerts
hydrostatic pressure.
Complete effacement and dilatation.
End of Stage 1
Friedman Curve
Predicable progression of labor for
Nulliparous and Multiparous
Responsibilities during
First Stage of Labor
• Promote Comfort
positioning, lighting
temperature, cleanliness
bladder, mouth care
• Relieve pain
breathing techniques
nonpharmacologic
massage, touch, pressure
hydrotherapy
imagery or focal point
Stage 2
From 10cm 100% to birth of Baby
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Assist mother with pushing
Preparation of sterile delivery table
Perineal cleansing
Sutures for episiotomy or laceration
Initial care and assessment of newborn
APGAR
Effects of labor on the fetal head. Caput succedaneum
formation.
Care of Infant
• Maintaining cardiopulmonary function –
APGAR
• Supporting thermoregulation
• Identifying infant
• Examining for obvious anomalies and birth
injuries
• Medication administration
Clamp is positioned 1/2 to 1 in from the abdomen
and then secured.
APGAR
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Heart rate – above 100
Respiratory Effort – spontaneous with cry
Muscle tone – flexed with movement
Reflex response – active, prompt cry
Color – pink or acrocyanosis
0-3 infant needs resuscitation
4-7 Gentle stimulation – Narcan
8-10 – no action needed
Cut cord. The one vein and two arteries can be seen.
Placenta Separation
Stage 3
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Uterus changes shape
Uterus rises upward in the abdomen
Cord begins to move out of the vagina
Gush of blood noted from vagina
Stage III
Placental separation and expulsion.
Schultze mechanism.
Stage 4 of Labor
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First 1-4 hours after delivery of placenta
Palpate fundus
Assess vital signs
Assess lochia
Ice pack to perineum
Care of infant and Care of mother
Identification
Promoting bonding
Suggested method of palpating the fundus of the
uterus during the fourth stage.
Common Intrapartum Procedures
• Amniotomy
• Stimulation of labor
induction
augmentation
• Assisted delivery
episiotomy
forceps
vacuum extractor
• Cesarean delivery
Amniotomy
• Artificial rupture of fetal membranes
• Advantages
decrease some labor
assessment of fluid for meconium
permits internal monitoring
• Risks
cord prolapse
infection
Assessment of Fluid
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Quality, Color, and Odor
Greenish, meconium stained
Large amount of vernix
Strong order, cloudy or yellow
Hydramnios
Oligohydramnios
Risk during ROM
Prolapse of the umbilical cord.
Induction & Augmentation of Labor
During Stage 1
• Definitions
• Criteria – Bishop’s scoring, 39 weeks gest.
• Methods
surgical – amniotomy
drugs
Oxytocin (Pitocin) – IV stimulate contractions
Cervical ripening agents prostaglandin
Misoprostol (Cytotec)- tab
dinoprostone (Prostin E2)
Cervidil/Prepidil - vaginal/cervical gel
Episiotomy
• Most common operation
primip – 70%
multip – 30%
• Types
midline – most common
problem with 3-4th degree laceration
mediolateral
increased PP pain, more scaring
Main risk – infection
Complication of infection – prolonged dysparenia
Prevention – perineal massage & stretching
beginning at 34 weeks.
Lacerations
• First degree - limited to fourchette,
perineal skin, vaginal membrane
• Second degree - underlying fascia and
muscle of the perineal body
• Third degree – involves the anal sphincter
• Fourth degree – extends thru the rectal
mucosa to lumen of rectum
Interventions During Stage 2
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Forceps & Vacuum Extraction
Assist with decent and rotation of fetal head
Risk- trauma to maternal and fetal tissue
Criteria
scalp is visible at vaginal opening
normal scalp ph is above 7.25
Low forceps - station is +2 or lower
Mid forceps - station 0 to +2
Forceps
With correct placement of the blades, the handles lock easily.
Vacuum extractor
Risks to Mother and Infant
• Mother
laceration
hematoma of the vagina
• Infant
ecchymoses
facial and scalp lacerations and abrasions
cephalhematoma
intracranial hemorrhage
• Chignon –scalp edema from vacuum extractor
Cesarean Birth
• About 22% of all births
• Indications – dystocia, CPD, PIH, DM,
genital herpes, prolapsed cord, fetal
malpresentations, placenta previa or
abruptio placentae
• Maternal risk same as any abdominal OR
• Infant’s greatest risk is lung immaturity
Preparation for C/S
• NPO, get operative permit signed
• Pre-op teaching
• Lab work – CBC, clotting series, type and cross
match one or more units
• Single IV dose of antibiotics
• Famotidine (Pepcid) and citrate (Bicitra)
• Shave abdomen
• Insert foley catheter
• Perform abdominal scrub
Incisions for C/S
• Abdominal incision
vertical – umbilicus to symphysis
transverse or bikini – above symphysis
• Uterine incisions
low transverse
low vertical
classic
• Abdominal and uterine incisions do not
always match
Low transverse incision
classic uterine incision
Nursing Considerations C/S
• Routine assessments q 15 min X 1 hr, q
30 min X 1 hr then hourly
VS
fundus for firmness, height, deviation
lochia
urine output
abdominal dressing
• Assess need for pain medication
• TCDB – support incision with pillow
Intrauterine Infection
• Signs
Fetal tachycardia – FHT greater than 169
Maternal fever – greater than 100.4
Foul or strong-smelling amniotic fluid
Cloud or yellow appearance to amniotic
fluid
Nursing Care for Infection
• Prevention
wash hands
limit vaginal examinations
keep under pads dry
• Assess VS q 4 hours if ROM than q 2 hrs
• Collect culture specimens
Intrapartum complications
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Dystocia
CPD – cephalopelvic disproportion
Placenta previa
Abruptio placenta
Prolapsed umbilical cord
Macrosomia - Shoulder dystocia
Dystocia
• Abnormal progress of labor
• Contributing factors
sedation, anxiety, anesthesia, unripe
cervix, supine position, cephlopelvic
disproportion - CPD
• Management
depends on cause
Complications of Pregnancy
Hemorrhage – late in pregnancy
Placenta Previa
Abruptio Placentae
Placenta previa
• Placenta located over/near cervical opening
• S&S: painless bleeding in 3rd trimester,
hemorrhage, fetal distress
• Risk factor: multiparity in older women
• TX: Hospitalization, bedrest, ultrasound
• Care: Do not perform vag exam
Monitor mother and fetus
Prepare for delivery / no oxytocin
Marginal (low-lying)
Placenta previa. Low placental implantation.
Total placenta previa
Abruptio Placentae
• Premature separation of placenta
• S&S: Concealed or apparent hemorrhage in
3rd trimester, uterine tenderness, abd Pain,
Board like abdomen, shock, fetal distress
• Risk factors: PIH, multiparty, DM
• TX: Replacement of blood loss, IV fluids,
delivery
• Care: Explain procedures, monitor mother and
fetal condition, prepare for delivery
Abruptio placentae.
Marginal abruption with external hemorrhage.
Abruptio placentae
Complete separation with concealed bleeding.
Shoulder Dystocia
• Risk factors
diabetes; macrosomic infant
obesity
prolonged second stage
previous shoulder dystocia
• Morbidity
• Management
Position for prolapse cord
Prolapsed Cord
• Cause – increase risk - high station,
AROM, poor fit, hydramnios, breech
• Signs of prolapse – visible, suspect
• Management – Emergency - Call Light
Reduce cord compression
Position hip higher than head
Hold fetal part upward
Give oxygen 8-10 liters/min
• Prompt delivery is the priority
Other Complications
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Precipitous delivery
Retained placenta
Uterine inversion
Uterine rupture
Umbilical cord problems
Multiple births