TCP Week 2 (Labor and Delivery)

what connects the fetus to the placenta?

umbilical cord

umbilical vein carries

carries blood TO the fetus

umbilical arteries carry

carry blood away from the fetus

Placenta consists of

blood vessels, vascular spaces and connective tissue

major functions of placenta

◦Metabolism of glycogen, cholesterol, and fatty acids

◦Transfer of substances by simple and facilitated diffusion and active transport

◦Secretion of protein and steroid hormones

maternal surface of placenta appearance

appears dark, resembles venous blood

circulation of maternal surface of placenta

circulation originates in the endometrial arterioles and blood is propelled into the intervillous space

fetal surface of placenta appearance

Shiny, smooth, large blood vessels coursing through the membranous surface

chorion

the membrane covering the fetal surface of the placenta

amnion

the innermost portion of the fetal membrane

chorion and amnion are separated by

a small amount of connective tissue

the fetal surface of the placenta should be investigated after delivery to

ensure that all of the placenta in intact

what are the three theories of causes of labor?

- oxytocin stimulation

- prostaglandin release causing uterine contractions

- illicit drugs

oxytocin role in causing labor

Levels of oxytocin in maternal blood in early labor are higher than before the onset labor

Relies on the presence of oxytocin receptors:

- Receptors are found in non-pregnant uterus but during pregnancy there is a 6-fold increase @ 15wks and an 80-fold increase @ term

prostaglandin role in causing labor

- Production found in fetal membranes

- Oxytocin stimulates prostaglandin synthesis

illicit drugs role in causing labor

- Pass through the placenta barrier and enter fetal circulation

- Fetus may have withdrawal signs

Labor characterized by

Characterized by contractions that occur at decreasing intervals with increasing intensity, this causes progressive cervical effacement and dilation

true vs false labor

Emergency Medical Treatment and Labor Act (EMTALA)

◦By law, all Medicare-participating hospitals with emergency services must provide an appropriate screening examination for any pregnant woman experiencing contractions and presenting to the emergency department for evaluation.

◦The definition of an emergency condition specifically refers to a pregnant woman experiencing contractions.

◦Labor is defined as "the process of childbirth beginning with the latent phase of labor, continuing through delivery of the placenta."

◦A woman in true labor is considered "unstable" for interhospital transfer purposes until the newborn and placenta are delivered.

◦A stable woman may, however, be transferred at the patient's direction or by a physician who certifies that the benefits of treatment at another facility outweigh the risks of transfer.

effacement

the gradual thinning, shortening, and drawing up of the cervix measured in percentages from 0-100%

Labor Stages *know*

•Stage One (Dilation)

•Stage Two (Expulsion)

•Stage Three (Placental Stage)

first stage of labor definition

labor onset until cervix is 10 cm/fully dilated (often longest part)

longest stage

- Primipara: 6-18hrs

- Multipara: 2-10hrs

first stage of labor - latent phase

Latent Phase: onset of labor --> active labor, defined by painful contractions that lead to slow cervical change

- Dilation 0-3cm

first stage of labor - active phase

Phase-more rapid cervical change (debated)

Dilation 4-7cm

◦Prim/Multipara should progress at least 1/1.2 cm/hr

◦Prim/Multi 0.5-0.7 cm/hr and 0.5-1.3 cm/hr

Arrest of labor: >6 cm dilated, ROM, and no progress for at least 4 hrs or at least 6 hrs of oxytocin

Clinical Management of First Stage

◦Maternal activity: Dependent upon status of membranes, fetal engagement

◦Assess fetal position (PE and/or U/S)

◦Encourage side-lying position when in bed

◦NPO or clear liquids; Begin IV fluids

◦Maternal monitoring: VS +I & O, uterine activity, vaginal exams for labor progress

◦Pain management/support

◦Fetal monitoring

Types of Cephalic Presentation

Types of Breech Presentation

Second Stage of Labor

Pushing and Delivery

Stage of expulsion of the fetus

Begins when dilatation of the cervix is complete (10cm) and ends with delivery of the fetus

◦Primipara: 30 min - 3 hrs, mean duration 50 mins

◦Multipara: 5-30 min, mean duration 20 mins

Duration can depend on anesthesia

clinical management of the second stage of labor

- Avoid supine maternal position

- Encourage bearing down with contractions

- Continuous fetal monitoring

- Vaginal exams to document descent

- Position mother, antiseptic scrub, drape

picture of the cardinal movements of labor

hardest part is the shoulders

Cardinal Movements of Labor

◦Engagement: 0 Station-BPD passes through pelvic inlet

◦Descent: fetal presenting part descends into pelvis

◦Flexion: fetal chin into contact with fetal thorax

◦Internal rotation: fetal head rotates from transverse to anterior-the occiput moves towards the pubic symphysis or posteriorly

◦Extension: head extends with crowning so it can pass

◦External rotation: head returns to transverse orientation

◦Expulsion: delivery of the anterior and posterior shoulders and torso of the baby are delivered

what to suction when the baby's head comes out?

suction the mouth FIRST then the nose

Delivery Procedures

- If amniotic sac has not broken?

- Determine if umbilical cord is?

◦If amniotic sac has not broken, puncture sac and pull away from baby's face

◦Determine if umbilical cord is around baby's neck. If so, either try to reduce it or clamp and cut cord

◦Note color of the fluid

describe the process of delivery (steps)

1. crowning of infant's head (prevent explosive delivery)

2. deliver head

3. suction mouth, then nose

4. aid in birth of upper shoulder (tilting down/traction down to get shoulder out)

5. aid in birth of posterior shoulder (tilt up)

6. support the trunk after ejection (and the head too duh)

7. support the legs after ejection

8. clamp or tie cord (closest to baby @ level height w mom), then cut

Cord Clamping

delayed cord clamping?

Initially, two clamps applied 6 to 8 cm from the fetal abdomen, later an umbilical cord clamp applied 2 to 3 cm

ACOG recommends delayed cord clamping for vigorous term and preterm neonates not needing immediate resuscitation at birth. (30-60 seconds)

◦Vigorous term neonates: Increases hemoglobin levels at birth and improves iron stores in 1st months of life

◦Preterm neonate, delayed cord clamping for > 30 seconds: Improved transitional circulation, better est. of RBC volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage.

Care of the Newborn

Position, dry, wipe, wrap

WARM, WARM, WARM

Repeat suctioning --> ISSUES ARISE FROM RESPIRATORY CAUSE, rarely cardiac

Cover the head

◦The head is the greatest area for heat loss

◦Hypothermia can have a very rapid onset

Third Stage of Labor

Stage of separation and expulsion of placenta

Begins immediately after delivery of the fetus and ends with delivery of the placenta and fetal membranes

◦Primipara: 0-30 min

◦Multipara: 0-30 min

signs of placental separation

- Usually within 2-10 minutes

- Uterus becomes globular in shape and firm

- Uterus rises upward in abdomen

- Umbilical cord lengthens

- Sudden gush of blood

clinical management of third stage of labor

Examine cervix/perineum for lacerations

Gentle traction on cord to facilitate expulsion

Counter pressure between symphysis & fundus to prevent descent of uterus

Prevention of uterine bleeding

- Uterine massage

- 20U of oxytocin added to IV infusion

Examine placenta to ensure complete removal

Repair episiotomy/lacerations as indicated

Perineal Lacerations

degrees?

◦1st degree - vaginal epithelium or perineal skin

◦2nd degree - subepithelium of vagina/perineum with or without involving muscles of perineum

◦3rd degree - involves anal sphincter

◦4th degree - involves rectal mucosa

◦Cervical lacerations

After Delivery Procedures

◦ Cover vaginal opening with sterile pad

◦ Record time of delivery

◦ Expect about 500cc blood loss with the normal vaginal delivery

◦ If blood loss is excessive, massage the uterus

◦ Best to place newborn skin to skin with mother

"stage four" of labor (duration and risks)

1-6h recovery stage; risk for hemorrhage due to:

- Uterine relaxation

- Retained placental fragments

- Lacerations

- Vaginal hematoma

"stage four" of labor: 1-6 hour recovery stage

clinical management focuses on:

-Frequent assessment of VS, bleeding, firmness of uterine fundus

-Comfort measures

-Preventing bladder distention

-Parent-newborn bonding (skin to skin contact)

-Encourage breastfeeding

-Providing food and fluids

Puerperium

•Period after delivery of the baby and placenta to 6 weeks PP

•Maternal bonding

•Breastfeeding initiated

Breastfeeding initiated PP

•Early BF beneficial to both mother and newborn

•Pairs that begin early are able to continue BF for longer periods of time

•Accelerates involution of uterus, reducing blood loss

•Maternal antibodies in breast milk which provide newborn with passive immunity against certain infections

Induction and Augmentation of Labor

induction - need to r/o? success correlate with?

artificial initiation of labor

-Rule out CI such as macrosomia, malpresentations, prior classic C/S incision

-Success correlates with Bishop score assigned

options for induction

-Prostaglandins used - cervidil, cytotec

-Stripping of membranes

-Oxytocin (Pitocin) infusion

-AROM-artificial rupture of membranes

Augmentation

stimulation of labor that began spontaneously

bishop scoring system is used to

determine the safety/need of labor induction

Oxytocin Infusion

•10U in 1000 ml D5W or balanced saline

•IV piggyback via infusion pump

•Dose increased incrementally according to protocol and contraction response

Oxytocin Complications

-Hyperstimulation with fetal distress

-Uterine tetany with possible rupture

-Uterine muscle fatigue with postpartum atony

pain relief options during labor

Nonpharmacologic methods (meditation, breathing)

Parenteral narcotics (fentanyl, butorphanol, nalbuphine); but NOT super close to delivery to avoid respiratory depression of infant

Regional anesthesia:

- Epidural, spinal, combined spinal-epidural

- Paracervical nerve block

- Pudendal nerve block

- Local

General anesthesia (emergencies, special situations)

Fetal Response to Labor

•Normal, healthy fetus with normal, healthy placenta can tolerate stress of contractions

•Compromised fetus or placenta may not tolerate stress of contractions resulting in fetal heart rate changes, hypoxia and acid-base imbalances

what is the goal of fetal surveillance during labor

to detect early signs of hypoxia and acidosis and intervene to preserve fetal health

list the types of fetal monitoring used

Intermittent Auscultation with Fetoscope

Electronic fetal monitoring

- External Fetal Monitoring

- Internal Fetal Monitoring

Fetal Heart Rate Monitoring Terminology

Baseline rate?

Tachycardia?

Bradycardia?

•Baseline rate—normally 110 to 160 bpm

•Tachycardia—FHR > 160 bpm

•Bradycardia—FHR < 110 bpm

Fetal Heart Rate Monitoring Terminology

Variability?

Accelerations?

Decelerations?

•Variability—minute fluctuations from baseline triggered by CNS control and environmental changes

•Accelerations—transient rise in FHR in response to fetal or uterine activity

•Decelerations (decels)—transient decrease from baseline in response to environmental changes or stress

list causes of fetal tachycardia

•Early hypoxia

•Increased fetal metabolism due to maternal fever

•Maternal dehydration

•Terbutaline

•Amnionitis (may be the first sign)

•Maternal hyperthyroidism

•Fetal anemia

list causes of fetal bradycardia

- Late (profound) fetal hypoxia leads to myocardia depression

- Maternal hypotension

- Prolonged umbilical cord compression

- Fetal Arrythmia

- Uterine hyperstimulation

- Abruptio placentae

- Uterine rupture

- Vagal stimulation (second stage)

list causes of decreased variability

- Hypoxia and acidosis (decreased blood flow to the fetus)

- CNS depressants

- Fetal sleep cycle (20 to 40 minutes duration)

- Fetal dysrhythmias

- Immature neurological control (fetus < 32 weeks EGA)

- Fetal anomalies affecting the heart, CNS, or autonomic nervous system

- Previous neurological insult

- Tachycardia

Fetal Heart Rate - Accelerations

◦Fetal Movement

◦Healthy Sign

◦Usually benign

◦Consider stage of labor

◦May be sign advanced dilation or beginning of second stage

fetal heart rate decelerations

Early—head compression, common during second stage

Late—uteroplacental insufficiency

Variable—umbilical cord compression

interventions for late decelerations

◦Left side

◦Oxygen on

◦Oxytocin off

◦Increase IV fluids

◦Consider tocolytic

- Magnesium sulfate

- Terbutaline

Variable Decelerations Cord Compression

Interventions

◦Change position

◦Oxygen on

◦Perform vaginal exam

◦Amnioinfusion may be attempted

reassuring fetal tracking

- Normal baseline

- Accelerations with fetal movement

- Present short-term variability

- Three to five cycles of long-term variability per minute

- Early decels may be present

nonreassuring fetal tracking

- Severe variable decels (FHR < 70 for > 30-45 seconds accompanied by rising BL, slow recovery, or decreasing variability)

- Late decels of any magnitude

- Absent variability

- Prolonged deceleration (> 60 to 90 seconds)

- Severe bradycardia (FHR baseline ≤ 70)

Post Partum

•Begins with birth

•Ends @ approximately 6wks

•"Fourth trimester"

•Must know norms and recognize variations

involution of the uterus

- Rapid reduction in size of uterus post birth to its pre-pregnant state

- Immediately after delivery large grapefruit mass midway between symphysis & umbilicus

- Within a few hours should be firm, well-contracted, midline and @ level umbilicus

- Fundal height decreases 1cm or 1 finger breadth per day

- Breastfeeding aids involution

- Placental site heals by exfoliation

Boggy Uterus

Bladder Interference

Intervention (image)

lochia

- Discharge which rids uterus of debris

- Classified according to appearance/contents

- document type and amount

what is expected progression of lochia

Lochia rubra: dark red, birth - 3rd day

Lochia serosa: pink to brown, 4th - 10th day

Lochia alba: white to yellow, 11th - 21st day

Alba = think Albino = white

foul odor lochia suggests

endometritis

benefits of breastfeeding

- Protects babies from infections and illnesses that include diarrhea, ear infections and pneumonia

- Breastfed babies are less likely to develop asthma

- Mothers who breastfeed have a decreased risk of breast and ovarian cancers

- Families who follow optimal breastfeeding practices can save between $1200-1500 on formula in the first year alone

Breast Changes

◦Progression from "soft" to "filling" to "full" as mature milk comes in 3-4 days

◦Colostrum to mature milk

◦Increased blood flow and mature milk leads to engorgement

◦Suckling stimulates prolactin, oxytocin

◦Supply & demand