Normal and Abnormal Labor and Delivery

what connects the fetus to the placenta

Umbilical cord

what carries oxygen-rich blood from the placenta to the fetus

umbilical vein

what carries deoxygenated blood and waste products from the fetus back to the placenta

umbilical arteries

functions of placenta

1. Metabolism of glycogen, cholesterol and fatty acids

2. Transfer of substances by simple and facilitated diffusion and active transport

3. Secretion of protein and steroid hormones

What is the appearance of the maternal vs fetal surface of the placenta

maternal → dark and resembles venous blood

fetal → Shiny and smooth

Placental circulation originates from

Endometrial arterioles

amnion vs chorion

amnion: innermost fetal membrane

chorion: membrane covering this surface of fetal membrane

Chorion and Amnion are separated only by a small amount of connective tissue

What does Oxytocin to exert its effect on the uterus to induce labor

Increase in Oxytocin receptors

6-fold increase @ 15wks
80-fold increase @ term

(this is why even though oxytocin lvls are higher in early labor than right before labor, oxytocin has larger effect due to the 80 fold inc in receptors at term)

What stimulates the production of prostaglandins and what does it do

oxytocin stimulates prostaglandin synthesis from fetal membranes → -cause uterine contractions

Define labor

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

**and is predictable

true vs false labor

True: regular intervals w gradually increasing intensity and progressive dilation. NOT affected by sedation

• back and abdomen

False: irregular intervals w steady intensity, no change in cervix and contractions can be relieved/stopped

• lower abdomen

labor stages

(DEP)

• Stage 1: Dilation 

• Stage 2: Expulsion

• Stage 3: Placental

Longest stage of labor

1st stage → dilation

Primipara (1st time birth): 6-18hrs;
Multipara: 2-10hrs

how is the dilation stage divided

3 phases:

1. latent → 0-3cm

2. active → 4-7cm

   1. Primipara - at least 1 cm/hr

   2. Multipara - at least 1.2 cm/hr

3. transition → 8-10cm

During the first stage of labor, what position is recommended for a patient lying in bed?

side lying position when in bed

Why are vaginal exams performed during the first stage?

To measure labor progress

what is normal cephalic presentation

vertex presentatiomn (complete flexion)

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

second stage → expulsion (pushing and delivery)

how long does 2nd stage of labor last

Primipara: 30 min – 3 hrs

Multipara: 5-30 min

What position should be avoided during expulsion stage of labor

Avoid supine position and encourage bearing down

What is the first cardinal movement of labor during the second stage?

Engagement → biparietal diameter of babys head passes pelvic inlet

During internal rotation, the fetal head rotates so that the occiput (back of head) moves toward which anatomical landmark

Pubic symphysis (normal) or posteriorly

All the cardinal movements of labor

1. engagement → biparietal diameter of head passes throught the pelvic inlet

2. descent → into pelvis

3. flexion

4. internal rotation → occiput (back of head) faces pubic symphysis

5. extension

6. external rotation → rotate back to align w body

7. expulsion → shoulders and rest of body are delivered

If the umbilical cord is found around the baby’s neck during delivery, what is the initial recommended action?

1. reduce it

2. clamp and cut

what to do if amniotic sac not broken during delivery

puncture sac and pull away from baby’s face

During delivery, what is the recommended order for suctioning the newborn’s airway?

Mouth then nose

What is the greatest area for heat loss in the newborn?

head

how long does 3rd stage of labor happen

delivery of placenta:

Primipara: 0-30 min

Multipara: 0-30 min

signs of placental seperation

1. uterus becomes globular and firm

2. Uterus rises upward in the abdomen (contracts to shrink)

3. Umbilical cord lengthens

4. Sudden gush of blood

how much blood loss expected after delivery

500 cc

how to prevent further uterine bleeding after delivery

1. massage uterus

2. 20U of oxytocin added to IV infusion

how ca you faciliate the expulsion of placenta

Gentle traction on the umbilical cord

how to prevent uterus from descending

Counter pressure between symphysis & fundus

describe the degrees of perineal lacerations

1. 1st degree – vaginal epithelium or perineal skin

2. 2nd degree – subepithelium of vagina/perineum with or without involving muscles of perineum

3. 3rd degree – involves anal sphincter

4. 4th degree – involves rectal mucosa

5. Cervical lacerations

what is stage 4 of labor

recovery stage → 1-6 hours after delivery when mother is at increased risk of complications

what increases the risk for hemorrhage during recovery stage

1. Uterine relaxation (which is why uterus contracts)

2. Retained placental fragments

3. Lacerations

4. Vaginal hematoma

Period after delivery of the baby and placenta to 6 weeks Postpartum is called

puerperium

How does early breastfeeding benefit the mother

1. accelerates involution of uterus (back to pre-preg size)

2. reduces postpartum bleeding

What type of immunity does breast milk provide to the newborn

passive

induction vs augmentation

induction → artificial initiation of labor

augmentation → stimulation of labor that began spontaneously

contraindications to induction of labor

1. macrosomia (very large baby)

2. malpresentation

3. prior classic cesarean section incision (vertical cut, which increases rupture risk)

what must be checked before inducing labor

1. lung maturity of fetus

2. any CI

   1. macrosomia

   2. malpresentation

   3. prior classic cesarean section (vertical incision)

what methods can be used to induce labor

1. prostaglandins: cervidil, cytotec

2. Stripping of membranes (Manual separation of membranes from cervix during vaginal exam to trigger prostaglandin release)

3. Oxytocin - pitocin

4. AROM (Artificial Rupture of Membranes) - Intentionally breaking the water to stimulate labor.

complications of oxytocin infusion

1. hyperstimulation → fetal distress

2. uterine tetany → risk of rupture

3. Uterine muscle fatigue → poor tone postpartum (uterine atony), leading to bleeding

narcotic examples for pain relief for labor

1. Fentanyl

2. butorphanol

3. nalbuphine

when is general anesthesia used for labor

Reserved for emergencies or special surgical situations

how may a Compromised fetus or placenta result?

1. fetal heart rate changes,

2. hypoxia

3. acid-base imbalances

• Fetal Surveillance During Labor

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

how can we monitor fetus

1. Intermittent Auscultation → requires 1:1 nurse-to-patient ratio

   1. Every 15 minutes during the first stage of labor

   2. Every 5 minutes during the second stage of labor

2. Electronic - External with ultrasound device and tocodynamomater

3. Electronic - Internal with spiral electrode and IUPC

normal fetal heart rate

110-160bpm

Variability

Small, moment-to-moment fluctuations in baseline FHR—reflects CNS function

accelerations vs decelerations

accelerations → Brief increase in FHR (often with fetal movement) — a good sign

decelerations → Decrease in FHR — may be normal or a warning, depending on type

causes of Fetal Tachycardia (>160)

1. Early fetal hypoxia

2. Maternal fever

3. Dehydration

4. Terbutaline (beta-agonist)

5. Amnionitis (infection – may be first clue)

6. Fetal anemia

7. Maternal hyperthyroidism

causes of fetal bradycardia (<110)

1. late/profound hypoxia (myocardial depression)

2. Maternal hypotension

3. Umbilical cord compression

4. Fetal arrhythmia

5. Uterine hyperstimulation

6. Uterine rupture

7. Vagal stimulation during second stage

8. Abruption

causes of decreased variability

1. Fetal hypoxia or acidosis

2. CNS depressant meds

3. Fetal sleep cycle (lasts 20–40 minutes)

4. Prematurity (<32 weeks)

5. Fetal cardiac or CNS anomalies

6. Neurological insult

7. Tachycardia

causes of early fetal heart rate decelerations

• head compression,

• common during second stage - usually benign

causes of late Fetal Heart Rate Decelerations

uteroplacental insufficiency

how to manage Late Decelerations Uteroplacental Insufficiency

1. Left side

2. Oxygen on

3. Oxytocin off

4. Increase IV fluids

5. Consider tocolytic (relaxes uterus)

   • Magnesium sulfate

   • Terbutaline

causes of Variable Decelerations

cord compression

how to manage Variable Decelerations

cord compression →

1. change maternal position (relieve pressure on cord)

2. Oxygen on

3. Perform vaginal exam

4. Amnioinfusion may be attempted (helps cushion cord by infusing sterile fluid into amniotic sac)

concerning fetal tracing

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

2. Late deceleration of any magnitude

3. Absent variability

   1. normal is 3-5 cycles of long-term variability per minute

4. Prolonged deceleration (> 60 to 90 seconds)

5. Severe bradycardia (FHR baseline ≤ 70)

postpartum

begins at birth and ends around 6 weeks after

postpartum management

1. early ambulation after delivery

2. diet → inc fluids and calcium intake of 1000mg/day (lactating)

3. bladder → watch for bladder distention and UTI

4. Perineum → ice, Gentle cleanse, Sitz baths, Pain medication-Tylenol, ibuprofen, dilaudid/oxycodone

5. Uterotonic (oxytocin) → prevent postpartum hemorrhage (PPH) by reducing uterine atony

6. Maternity blues (50-70%) →Self-limiting by day 10 and doesn’t require treatment unless prolonged

when can resume sexual acitivty

around 6 weeks postpartum, once healing is complete

(but Normal sexual response may take up to 12 weeks to return)

what immunizations should you consider for postpartum mothers

1. Rhogam – for Rh-negative mothers if baby is Rh-positive

2. Rubella – if not immune, give after delivery (live vaccine)

3. Influenza – safe during and after pregnancy

Uterine Involution

The process of the uterus returning to pre-pregnancy size and position

where should uterus be within a few hours after delivery

firm, midline, at umbilicus level

Decreases ~1 cm/day or 1 finger breadth/day

Lochia

Discharge that helps expel uterine debris after birth

what does foul smelling lochia suggest

endometritis

Lochia rubra

• dark red, birth – 3rd day

Lochia serosa

pink to brown,  4th – 10th day

Lochia alba

white to yellow, 11th – 21st day

how long is it recommended to breastfeed

• American Academy of Pediatrics → at least 12 months and thereafter for as long as mother and baby desire

• World Health Organization → continued breastfeeding up to 2 years of age or beyond

Breastfeeding Benefits

1. protect from infections and illnesses like diarrhea, ear infections, and pneumonia

2. less likely to develop asthma

3. mothers dec risk of breast and ovarian cancers

4. save between $1200-1500 on formula in the 1st year alone

what hormones are triggered by suckling

1. prolactin

2. oxytocin