OB Review 2
February 2009
True Labor
Contractions produce progressive
dilatation and enfacement of the cervix.
Occur regularly and increase in frequency,
duration, and intensity.
The discomfort of true labor contractions
usually starts in the back and radiates
around to the abdomen
Not relieved by walking.
FACTORS THAT MAY EXTEND OR INFLUENCE
THE DURATION OF LABOR - 4 Ps
 Passage: Birth Passage: size and morphology of true
pelvis, uterus, cervix, vagina, and perineum. Parity of
woman.
 The True Pelvis is a primary concern when a vaginal
delivery is expected.
 Passenger: Presentation of the fetus “part of the fetus
that enters the pelvis first” (breech, transverse). Size of
the fetus, moldability of the fetal skull.
 Powers: Quality, force and frequency of uterine
contractions
 Psyche: mother’s attitude toward labor and her
preparation for labor. Culture, Anxiety/Fear
Passenger
 Fetal Presentation – Referred to the fetal
presenting part. Part of the fetus that enters the
pelvis first:
Cephalic –presentation of any part of the fetus
head during labor - Vertex
Breech
Shoulder.
 Fetal attidude – Relationship of fetal parts to
one another: all joints in flexion
 Fetal lie – Relationship of cephalocaudal axis
(spinal column) of fetus to the cephalocaudal axis
of mother- transverse, parallel
The fetal head normally engages in the maternal pelvis in
an occiput transverse position,
 the vertex is formed
by four bones of the
Skull: the frontal bone,
the 2 parietal bones
and the occipital bone.
 In a vertex position when
the occiput bone is the
presenting part it refers to
an occiput position.
Vertex Presentation is a normal presenting position
 Left occiput anterior
Positioning During Labor
 Assist the patient in turning from side to side.
 Side-lying promotes uteroplacental blood flow.
 Elevate the head of the bed 30 degrees; this
makes it easier for the patient to breathe.
 May result in pressure of the enlarged uterus on
the vena cava, reduces blood supply to the heart,
decreases blood pressure, and reduces blood
circulation to the uterus and across the placenta
to the fetus.
 The best position for the patient is on her left side
since this increases fetal circulation.
Characteristics of Contractions
Frequency: How often they occur?
They are timed from the beginning of a
contraction to the beginning of the next
contraction.
Regularity: Is the pattern rhythmic?
Duration: From beginning to end - How
long does each contraction last?
Intensity: By palpation mild, moderate, or
strong.
3/15/2016
8
Average Length of Labor
.
Latent
Active
Transition Second
stage
Primigravida 8 – 10
hours
6 hours 2 hours
1 hour
Multigravida 5 hours
4 hours 1 hour
15
minutes
Assessment of Contractions
Palpation: Use the fingertips to palpate the
fundus of the uterus
Mild: Uterus can be indented with gentle
pressure at peak of contraction – feels like tip of
nose
Moderate: Uterus can be indented with firm
pressure at peak of contraction - feels like chin
Strong: Uterus feels firm and cannot be
indented during peak of contraction – feels like
the forehead
3/15/2016
10
Impending signs of Birth




Impending Signs of birth
Bulging of the perineum.
Crowning
Dilatation of the anal
orifice.
 Complaints of severe
discomfort.
 Dilatation and effacement
– complete - patient is
instructed to push with
each contraction to bring
the presenting part down
into the pelvis
Amniotomy
 Artificial rupture of
membranes performed at or
beyond 3 cm dilation.
 May cause changes in the
FHR ( accelerations or
bradycardia).
 Assess and monitor FHR for
one full minute
 Normal amniotic fluid is
straw-colored and odorless.
Stage 1
Latent:
ends 4 cm
Active:
begins 4 cm
ends 8 cm
Transition:
begins 8 cm
ends 10 cm
Stage 1 - Transition Phase
 Begins when cervix is dilated
8 cm, ends when cervix is
dilated 10 cm.
 Contractions occur every 2 to
3 minutes
 Duration of 60 to 90 seconds.
 The intensity of contractions
is strong.
 Completion of this phase
marks the end of the first
stage of labor.
 Urge to push or to have a BM
2nd Stage: Birth of the Baby
 Begins when cervical
dilatation is complete and
ends with birth of the baby.
 Dilatation and effacement –
complete - Patient is
instructed to push with each
contraction to bring the
presenting part down into
the pelvis
Third Stage of Labor
 The period from birth of the baby through delivery
of the placenta.
 Dangerous time because of the possibility of
hemorrhaging.
 Signs of the placental separation
 a. The uterus becomes globular in shape and
firmer.
 b. The uterus rises in the abdomen.
 c. The umbilical cord descends three inches or
more further out of the vagina.
 d. Sudden gush of blood.
4th stage
Period from the delivery of the placenta
until the uterus remains firm on its own.
Uterus makes its initial readjustment to the
non-pregnant state.
The primary goal is to prevent hemorrhage
from the uterine atony and the cervical or
vaginal lacerations.
Atony is the lack of normal muscle tone.
Uterine atony is failure of the uterus to
contract.
Fourth Stage of Labor
Referred as the Recovery Stage
First 4 hours after the birth.
Blood loss is usually between 250 mL and
500 mL.
Uterus should remain contracted to control
bleeding, positioned in the midline of the
abdomen, level with the umbilicus.
Mother may experience shaking chills.
Intrathecal Block
Injected into the subarachnoid space
Rapid onset
Less sedation
No hypotension or motor block
Precipitated Birth
 Suddenly occurring and unexpectedly without a
physician or midwife to assist.
 Nursing intervention:
 Stay with mother
 Call for assistance
 Remain calm
 Open emergency birth pack
 Scrub if time permits
 As head crowns instruct mom to pant
 Suction newborn’s mouth and nose to
prevent aspiration
UMBILICAL PROLAPSE CORD
1. Cord is protruding from the vagina.
 Goal is prevention of fetal anoxia.
 Management includes positioning
the mother on the left side in
trendelenberg or in a knee-chest
position and administering 100%
oxygen.
 If the cord is exposed, cover it with
saline moistened sterile gauze.
STAT C-section is performed.
 Insert 2 fingers into the vagina
with sterile gloves, and put
pressure on the presenting part to
relieve the compression of the
cord.
Oxytocin Infusion Safety
Discontinue infusion with oxytocin if the
following occur:
Contractions are more frequent than every
2 minutes or duration is more than 90
seconds
Uterus resting tone is more than 20 mm hg
Fetal monitor shows: repeated late
decelerations, prolonged decelerations or
no variability
 Birth of an infant
through an incision in
the abdomen and
uterus.
 Scheduled or
unscheduled.
 When C/Section is
unscheduled: the nurse
needs to review with
the client events before
the C/Section to ensure
the client understands
what happened
CESAREAN BIRTH
The Postpartum Period
Puerperium: Term 1st 6 weeks after the
birth of an infant
Neonate–newborn from birth to 28 days.
Family adaptation to neonate: Bonding–
rapid process of attachment during 1st 30
to 60 minutes after birth
Mother, father, siblings, grandparents
Uterine Involution
 Uterine Involution: return
of the uterus to its prepregnancy size and
condition.
 Normal postpartum uterus
is firm and at midline
 Uterine fundal descent:
uterus size of grapefruit
immediately after birth
 Fundus rises to the
umbilicus stays for 12
hours
 Descends 1 cm
(fingerbreadth) each day
for about 10 days
Lochia Assessment
 Lochia–vaginal discharge after childbirth.
 It takes 6 weeks for the vagina to regain its prepregnancy contour.
 Lochia: scant-moderate, rubra, serosa or alba
 Assessment of lochia includes noting color,
presence and size of clots and foul odor.
 Day 1- 3 - lochia rubra (blood with small pieces
of decidua and mucus)
 Day 4-10 – lochia serosa (pink or pinkish brown
serous exudate with cervical mucus, erythrocytes
and leukocytes)
 Day 11- 21 - lochia alba (yellowish white
discharge)
Episiotomy Pain Relief
Instruct Mother:
Tighten her buttocks and perineum before
sitting to prevent pulling on the episiotomy
and perineal area and to release
tightening after being seated.
Rest several times a day with feet
elevated.
Practice Kegel exercise many times a day
to increase circulation to the perineal area
and to strengthen the perineal muscles.
Breast Assessment
Breasts: Soft, engorged, filling, swelling,
redness, tenderness.
Nipples: Inverted, everted, cracked,
bleeding, bruised, presence of colostrum or
breastmilk.
Colostrum–yellowish fluid rich in antibodies
and high in protein.
Engorgement occurs by day 3 or 4. Due to
vasoconstriction as milk production begins
Lactation ceases within a week if
breastfeeding is never begun or is stopped.
Postpartum Psychosis
 A very serious type of PPD
illness that can affect new
mothers.
 Begin 2-3 weeks post delivery
 Fatigue, restlessness,
insomnia, crying liable
emotions, inability to move,
irrationally statements
incoherence confusion and
obsessive concerns about the
infant’s health
 Psychiatric emergency
Nipple soreness is a portal of entry for
bacteria - breast infection (Mastitis).
Maternal after pains: may be due to
breastfeeding and multiparity (loss of
uterine tone)
Always stay with the client when getting
out of bed for the first time – hypotension
effect and excess bleeding
When assessing fundal height, if you
notice any discrepancies in fundal height
have patient void and then reassess.
Postpartum Cesarean
 Incision site…redness swelling, discharge. Intact?
 Abdomen soft, distended? Bowel sounds heard all
4 quadrants
 Flatus?
 Lochia is less amount than in normal
spontaneous vaginal delivery (NSVD) because
uterus is wiped with sponges during c/section.
 If lochia indicates excessive bleeding, combine
palpation and pain management measures.
 Auscultate breath sounds
 Fluid intake and output
 Pain?
Assessment of Edema & Homan’s Sign
 Assess legs for presence and degree of edema;
may have dependent edema in feet and legs.
 Assess for Homan’s sign- thromboembolism
 Negative Homan’s Sign is with No PAIN
 If there is pain then it is positive (+) and the nurse
needs to report this finding immediately to the
health care provider.
 Press down gently on the patient’s knee (legs
extended flat on bed) ask her to flex her foot
(dorsiflex)
RhoGAM
 It is given to an Rh- mother within 72 hours after
delivery of an Rh+ infant or if the Rh is unknown.
Most people have Rh-positive blood. (Rh
Factor)
An inherited protein found on the surface of
RBCs.
A minority of individuals lack the Rh factor
and are considered Rh-negative.
If the baby's Rh positive blood enters a mother
who is Rh Negative, then her immune system
sees the cells as 'foreign' and will produce antirhesus antibodies to try to destroy them for her
own self-protection.
Thromboembolic Conditions
Thrombophlebitis–the formation of a clot in
an inflamed vein.
Risk factors include maternal age over 35,
cesarean birth, prolonged time in stirrups,
obesity, smoking, and history of
varicosities or venous thromboses.
Prevention: client needs to ambulate
early after delivery.
Respiratory Distress
Respiratory Distress Syndrome (RDS)
RDS: preterm infants/surfactant deficiency
Hypoxia, respiratory acidosis and
metabolic acidosis
Surfactant is produced by alveoli - lung
maturity
L/S ratio (lecithin-to-sphingomyelin
ratio) is a test done before birth to
determine fetal lung maturity.
These phospholipids stabilize alveoli so
that they do not collapse on exhalation
Prophylactic Care
Vitamin K –to prevent hemorrhagic
disorders – vit k (clotting process) is
synthesized in the intestine requires food
for this process.
Newborn’s stomach is sterile has no food.
aquaMEPHYTON
Hepatitis B vaccination –within the first 12
hours
Eye prophylaxis –(Erythromycin Ointment)
to prevent ophthalmia neonatorum –
gonorrhea/chlamydia
The Head and Chest
 The Head: Anterior
fontanel diamond shaped
2-3 - 3-4 cms
 Posterior fontanel
triangular 0.5 - 1 cm
 Fontanels soft, firm and flat
 head circumference is 33 –
35 cm
 The head is a few
centimeters larger than the
chest!!!!
 The Chest: circumference
is 30.5 – 33 cm
Vital Signs normal
 Temperature - range 36.5 to 37 axillary (97.7-98.6)
 Axillary vs Rectal about 0.2 to 0.5 difference
Common variations
 Crying may elevate temperature
 Stabilizes in 8 to 10 hours after delivery
 Heart rate - range 120 to 160 beats per minute
 Apical pulse for one minute
Common variations
 Heart rate range to 100 when sleeping to 180 when crying
 Color pink with acrocyanosis
 Heart rate may be irregular with crying
 Respiration - range 30 to 60 breaths per minute
 Blood pressure - not done routinely
 Ranges between 60-80 mm systolic and 40-45 mm diastolic.
Common Normal Variations
Acrocyanosis - result of sluggish peripheral
circulation.
Mongolian Spots: Patch of purple-black or blueblack color distributed over coccygeal and sacral
regions of infants of African-American or Asian
descent.
 Milia: Tiny white bumps papules (plugged
sebaceous glands) located over nose, cheek,
and chin.
 Erythema toxicum: Most common newborn rash.
Variable, irregular macular patches. Lasts a few
days.
Erythema toxicum, acrocyanosis, milia and mongolian
spots
Caput succedaneum
 Swelling of the soft tissue
of the scalp caused by
pressure of the fetal head
on a cervix that is not fully
dilated.
 Swelling is generalized.
may cross suture line and
decreases rapidly in a
few days after birth.
Requires no treatment
 2 – 3 days disappears
Cephalohematoma
 Collection of blood
between the periosteum
and skull of newborn.
 Does not cross suture
lines
 Caused by rupturing of
the periosteal bridging
veins due to friction and
pressure during labor.
 Lasts 3 – 6 weeks
Normal Reflexes
 Tonic Neck Reflex (FENCING)
 EXTENDS arm & leg on the side
that the face points.
 Flexes opposite arm & leg
 6-8 wks to 6 months




Babinski Reflex is (+)
This is Normal
Birth to after walking
12-18 months age
Gestational Age Relationship to Intrauterine Growth
Normal range of birth weight for each week
of gestation.
Birth weight is classified as follows:
Large for gestational age (LGA): weight falls
above the 90th percentile for gestational age
Appropriate for gestational age (AGA):
weight falls between the 90th and 10th
percentile for gestational age
Small for gestational age (SGA): weight
falls below the 10th percentile for gestational
age
Newborn – Term vs Preterm
 The premature newborn has no flexion of
extremeties
 Full term newborn is fully flexed.
 Skin in a preterm is very transparent and thin
 Veins disappear as subcutaneous fat is
deposited.
 Lanugo is most abundant at 28 to 30 weeks
gestation a small amount may remain at full term
 Eyelids are fused until 26 to 28 weeks gestation
 Ears when folded remains folded at 32 weeks
and by 36 weeks there is enough cartilage for
the ear to return to its original state when folded.
Bathing the Newborn
 No tub bath until after
the cord has fallen off
and healing is
complete.
 Newborn’s first baththe nurse needs to
wear gloves to
prevent infection.
 What is wrong with
this nursing action?
Circumcision
 Circumcision is considered an elective
procedure
 Anesthesia should be provided.
 Parents must give written consent
 Full term health infants
 Aftercare: Check hourly for 12 hours
 Check for bleeding and voiding
 Before discharge:
 Newborn goes home within the first 12 hours
after procedure
 Bleeding should be minimal and infant must
void
Breastfeeding
 Colostrum is rich in immunoglobulins to protect
newborn GI tract from infection; laxative effect.
 Breast milk in 2 weeks sufficient nutrients 20
kcal/oz (infant’s nutritional needs)
 To support Breastfeeding: Mother needs to
consume extra 500 calories per day.
 Feeding length: should be long enough to
remove all the foremilk (watery 1st milk from
breast high in lactose - skim milk & effective in
quenching thirst)
 Hindmilk: higher in fat content leads to weight
gain and more satisfying.
 Breastfeeding time approximately 30 minutes
Infant Formula
Formula 7.5 ml to 15 ml at feeding
gradually increase to 90 ml to 120 ml at
each feeding in 2 weeks.
Formula preparation: mixing must be
accurate to provide the 20 kcal/oz.
(newborn nutritional need)
Burping: is needed to expel air swallowed
when infant sucks.
Should be done about halfway through
feeding for bottle feeders and when
changing breasts for breast feeders.
Hyperbilirubinemia
 Physiologic Jaundice =Appears 24 hours after
birth peaks at 72 hrs.
 Bilirubin may reach 6 to 10 mg/dl and resolve in 5
to 7 days.
 Due to Unconjugated bilirubin circulating in the
blood stream that is deposited in the skin.
 Immature liver unable to conjugate bilirubin
released by destroyed RBC.
 Pathologic Jaundice =Not appear until after 24
hrs leads to Kernicterus (deposits of bili in brain).
 Bilirubin >20mg/dl
 The most common cause is Rh incompatibility.
Neural Tube Defects
 3 types:
 Spina Bifida Occulta: failure of the vertebral arch
to close. Has dimple on the back with a tuft of hair.
No treatment required.
 Meningocele: saclike protrusion along the
vertebral column filled with cerebrospinal fluid and
meninges. Surgery required.
 Myelomeningocele: saclike protrusion along the
vertebral column filled with spinal fluid meninges,
nerve roots, and spinal cord = paralysis. Surgical
repair required.
 Sterile saline dressing.
 hydrocepalus
 Spina bifida occulta
 Spina bifida Occulta
 meningocele
 myelomeningocele
Infants of DM mothers (IDM) Complications
 Hypoglycemia: maternal glucose declines at
birth. Infant has high level of insulin production=
decreases infant’s blood glucose within hours
after birth.
 Respiratory Distress: less mature lungs due to
insulin
 Hyperbilirubinemia: hepatic immaturity,
increased hematocrit, bruising due to difficult
delivery.
 Birth trauma: large size of infant
 Congenital birth defects: birth defects – Patent
Ductus Arteriosus, Ventricular Septal Defect
and more.