Module 4: Nursing care of the patient during labor and delivery (Part 1 - 2)

Dystocia

• difficulty labor is characterized by abnormally slow progress of labor

• most common contemporary indication for primary cesarean section

• abnormalities on the ff: passenger, pelvis, powers, and birth canal

Labor

• series of events by which uterine contractions and abdominal pressure expel the fetus and placenta from the woman’s body

Delivery

• actual event of birth

Factors affecting labor

1. passenger

2. passageway

3. powers

4. placenta

5. psyche

6. position of the laboring woman

passenger components

• fetal bones

• suture lines

• fontanels and head measurement

• fetal lie, attitude, presentation, position, and station

passageway components

• gynecoid

• anthropoid

• android

• platypelloid

Powers components

• strength

• duration and frequency of uterine contractions

• involuntary urge to push

• interval and intensity

Placenta

site of insertion of placenta

Psyche components

• psychological state of the woman

• stress factors leading to hypotonia

Labor position

• walking

• standing

• leaning

• tailor sitting

• semi recumbent

• hand knees

• squatting

• kneeling and leaning forward with support

Delivery position

• lithotomy

• semi recumbent

• lateral recumbent

• squatting

passenger

• abnormalities of presentation and position

  • occiput posterior

  • breech, face, brow presentation

• macrosomia

• conjoined twins

• multiple pregnancy

Fetal Position

• relationship of reference point on fetal presenting part to maternal bony pelvis

  • occiput (vertex presentation

  • mentum or chin (face presentation)

  • Sacrum (breech presentation

  • Acromion (shoulder presentation)

Favorable/ Most common fetal position

• Right Occiput Anterior

• Left Occiput Anterior

Transverse position

• right acromio dorso posterior position

• the shoulder of the fetus is to the mother’s right, and back is posterior

LOP or ROP

usually causes back pain during labor; may slow the progress of labor; may slow the progress of labor; usually rotates before delivery to anterior position; rotation may be done by physician

Methods to establish fetal position/ presentation

• combined inspection and palpation (LM)

• vaginal examination

• auscultation of fetal heart tones

• sonography

• x-ray

fetal presentation

• is defined as the lowermost part the fetus which presents to the pelvis/ lower uterine segment

• determined by vaginal examination during labor

Types of presentation

1. cephalic

2. breech

3. shoulder

4. compound

types of cephalic presentation

1. vertex/ occiput

2. brow

3. sinciput

4. face

types of cephalic breech presentation

1. frank

2. complete

3. incomplete

Malpresentation

• is presentation other than the vertex presentation

  • breech 3%

  • face 0.2%

  • brow 0.01%

  • shoulder 1:300

  • compound 1:1000

breech presentation

• buttocks or lower extremities’ present first

Frank breech position

thighs flexed, legs extended on anterior body surface, buttocks presenting

full/ complete breech position

• thighs and legs flexed, buttocks and feet

• baby is squatting position (Indian sit)

Footling breech position

one or both feet are presenting

predisposing factor of breech position

• placenta previa

• multiple pregnancy

• uterine anomalies

• polyhydramnios/oligohydramnios

• multiparity

• abnormal motor ability/ diminished tone

• uterine relaxation

Types of breech deliveries

1. spontaneous breech

2. assisted breech

3. total breech extraction

spontaneous breech delivery

• no traction or manipulation of the infant is used

• this occur predominantly in very preterm deliveries

Assisted breech delivery

• most common type of vaginal breech delivery

• spontaneously deliver up to the umbilicus

• maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head

• if legs do not deliver spontaneously can be assisted by pinard maneuver

total breech extraction

• fetal feet are grasped, and the entire fetus is extracted

• noncephalic second twin

• for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%

predisposing factor of face presentation

• conditions which favor extension and reduce flexion to the vertex

• multiparity

• prematurity

• CPD

Face presentation

• according to the position of the chin (mentum)

• can deliver vaginally if mento-anterior (occiputs fits into the hollow of the sacrum allowing delivery of the chin under the symphysis)

• 1/3 begins as M-P and 2/3 rotates to M-A

• submentobregmatic diameter presented to pelvis (9.5 cm)

Management of Face presentation

• re-evaluate and make preliminary choice before delivery

• VD appropriate where labor progressing satisfactorily, average size baby and adequate sized pelvis

• rotation to M-A may occur late in the second stage

• Maneuvers to manually flex the face to facilitate delivery abandoned in modern obstetric practice

• forceps rotations C/I

• outlet forceps for M-A position

• CS for persistent non M-A position

brow presentation

• moderate degree of deflexion

• mento-occiput diameter presented to the pelvis (12.5 cm)

• may be a transient feature of labor

• 2/3 of cases are understandable and convert

Management of brow presentation

• re-evaluate

• manual flexion and rotation to OA sometimes possible

• C/S for persistent brow

shoulder presentation

• the long axis of the fetus is perpendicular to that of the mother

• is usually over the pelvic inlet, with the head lying in one iliac fossa and the breech in the other

predisposing factor of shoulder/transverse presentation

• placenta previa

• multiple pregnancy

• uterine anomalies

• prematurity

• polyhydramnios

• multiparity

management of shoulder/ transvers presentation

• if >37 weeks without C/I consider ECV

• if in labor or C/I to ECV exist deliver by CS

• type of uterine incision needs to be considered- classical, low transverse with primary purpose to avoid fetal trauma and asphyxia

Compound

• implies that another anatomic part usually an extremity has entered the pelvis along the with principal vertex or breech presentation

Predisposing factor of compound

• prematurity

• abnormal lies

• fetal anomalies

• large pelvic capacities

compound management

• labors usually normal

• problem usually solved with the head being forced past the extremity

• cord prolapse a possible complication

• may encourage the fetus to remove the extremity

• consider C/S for usual causes or arrest of labor

• edema/discoloration of the extremity quickly resolve

Multiple pregnancy

• when more than one fetus simultaneously develops in the uterus

• simultaneous development of two fetuses is the commonest

Dizygotic twins

• commonest ratio of multiple pregnancy

• result from the fertilization of two ova

• fraternal, binovular; 2 sperms and 2 eggs

• separate placenta

Monozygotic twins

• result from the fertilization of single ovum

• identical, uniovular; 1 sperm & 1 egg

• same placenta; separate amniotic sacs

diamniotic dichorionic

• 72 hours after fertilization

• two separate placenta, chorions and amnions

diamniotic monochorionic

• 4-8 days after inner cell mass when chorion had developed

monoamniotic monochorionic

• after 8th day of fertilization when amniotic cavity is formed

Etiology of twin pregnancy

• maternal age

• race and heredity

• parity: increasing parity

• pituitary gonadotropin

• ART (Assisted reproductive technology)

  • ovulation induction with FSH and gonadotropin/chlomiphine

  • Greater the number of embryos transferred, the greater the risk of multiple pregnancy

Conjoined twins

• divisions occurs after 2 weeks of the development of embryonic disc

• Siamese twins

• four types of fusion may occur

  • thoracopagus (commonest)

  • Pyopagus (posterior fusion)

  • Craniphagus (cephalic)

  • Ischiopagus (caudal)

Twin pregnancy maternal complication: during pregnancy

• nausea and vomiting

• anemia

• pre-eclampsia

• hydramnios

• antepartum hemorrhage

• malpresentation

• preterm labor

• mechanical distress

Twin pregnancy maternal complication: during labor

• early rapture of membranes

• cord prolapse

• prolonged labor

• increased operative interference

• bleeding

• postpartum hemorrhage

Twin pregnancy maternal complication: during puerperium

• subinvolution

• infection

• lactation failure

Twin pregnancy: fetal complications

• miscarriage

• prematurity

• growth problem

• intrauterine death

• asphyxia and stillbirth

• fetal anomalies

Locked twins

• first fetus breech and the second is cephalic, breech of the first twin descends through the birth canal, the chin locks between the neck and chin of the second cephalic presenting co twin

twin to twin transfusion syndrome

• unbalanced distribution of nutrition and fetal development (one might appear to be a runt baby)

passageway

• refers to the route the fetus must travel from the uterus through the pelvis

  • soft tissue

  • pelvic bone

soft tissues of the passage

• distensible lower uterine segment

• cervix

• vaginal canal

• pelvic floor muscle

• introitus

important factors in the passageway

• type of pelvis

• structure of the pelvis

• pelvic inlet diameters

• ability of the uterine segment & vaginal canal to distend, the cervix to dilate

2 divisions of pelvis

1. false pelvis

2. true pelvis

components of true pelvis

1. pelvic inlet

2. pelvic cavity

3. pelvic outlet

Gynecoid

• true female pelvis

• 50%

• slight ovoid brim

• moderate depth

• straight side wall

• blunt ischial spines

• curved sacrum

• wide suprapubic arch

• good for vaginal delivery

platypelloid

• wide but flat,

• kidney-shaped brim

anthropoid

• oval in shape.

• transverse diameter is narrow, A-P is longer.

• ape shape pelvis

• 24%

• deep depth

• straight side wall

• prominent ischial bones

• slightly curved sacrum

• narrow suprapubic arch

• Good for vaginal and forcep delivery

android

• heart shape

• male pelvis

• 23%

• deep depth

• convergent side wall

• prominent ischial spines

• slightly curved sacrum

• narrow suprapubic arch

• good for CS and Vaginal deliver; difficult with forcep delivery

Passageway measurement: adequacy of pelvic size

1. diagonal conjugate (AP diameter of the inlet)

2. transverse diameter of the outlet

pelvic inlet measurements

1. diagonal conjugate (12.5-13 cm)

2. obstetric conjugate (estimated subtracting 1.5 - 2 cm to diagonal conjugation)

3. true conjugate (10.5 - 11 cm)

Diagonal conjugate

• from the lowest margin of the symphysis pubis to sacral promontory

• measurement: 12.5 - 13 cm

• obtained by vaginal examination

Obstetric conjugate

• from inner surface of symphysis pubis, slightly below upper border to sacral promontory

• shortest distance between sacral promontory and symphysis pubis

• most important pelvic measurement

• subtracting 1.5-2cm from diagonal conjugate

True conjugate

• conjugate vera

• from upper margin of symphysis pubis to sacral promontory

• measurement: 10.5 - 11 cm

• maybe obtained by x-ray or ultrasound

Interspinous diameter/bispinous diameter

• at the level of the ischial spine

• Importance: engagement of the fetal head

• the space between the inlet and the outlet

• extends from the lower margin of the symphysis pubis through the level of the ischial spines to the tip the sacrum

• measurement: 10.5 cm

Midpelvis measurement

• the anteroposterior diameter through the level of ischial spines - 11.5 cm

• transverse or interspinous - 10.5 cm

• posterior sagittal - from the midpoint of the interspinous line to the same point in sacrum 5 cm

AP diameter

extends from the lower margin of the symphysis pubis to the tip of the sacrum (11.5)

Transverse diameter/ Inter ischial tuberous diameter

distance between the inner edges of the ischial tuberosities (10 cm)

posteriori sagittal diameter

extends from the tip of the sacrum to a right angled intersection with a line between the ischial tuberosities (7.5 cm)

Outlet

• inferior portion of the pelvis, or that portion bounded in the back by coccyx, on the sides by ischial tuberosities and in the front by the inferior aspect of the symphysis pubis

Engagement

• fetal presenting part enters true pelvis (inlet)

• may occur two weeks before labor in Primipara; usually occurs at the beginning of labor for multipara

station

• measurement of how the presenting part has descended into the pelvis

• referent is ischial spines, palpated through lateral vaginal walls

• high or floating terms used to denote unengaged presenting parts

• ischial spine = 0

• above ischial spine = negative numbers

• below ischial spine = positive numbers

2 transverse diameters

1. biparietal diameter

2. bitemporal diameter

biparietal diameter

• 9.5 cm between 2 parietal eminences

bitemporal diameter

• 8.2 cm between the furthest points of the coronal sutures of the temples

AP or longitudinal diameters

1. suboccipitobregmatic

2. suboccipitofrontal

3. Occipitofrontal

4. Mentovertical or occipitomental

5. submentovertical

6. submentobregmatic

suboccipitobregmatic

• 9.5 cm from inferiror aspect of the occiput to the center of the anterior fontanelle

suboccipitofrontal

• 10 cm from below the occipital protruberance to the center of the frontal suture

Occipitofrontal

• 11.5 cm bridge of the nose to the occipital prominance

Mentovertical or occipitomental

• 13.5 cm measured from chin to the posteriori fontanelle

• widest AP diameter

Submentovertical

• 11.5 cm from the point where the chin joins the neck to the highest point on the vertex

submentobregmatic

• 9.5 cm from the point where the chin joins the neck to the center of the bregma

contacted pelvis

is defined as one in which the essential diameters of one or more planes are shortened by at least 0.5 cm.

clinical pelvimetry

• determination of adequacy of the inlet reaching the promontory of the sacrum

assessment of the pelvis

1. reaching the sacral promontory

2. feeling the lateral pelvic wall

3. determining the prominence of the ischial bones

4. assessment of the pubic arch

Muller Hellis Method

• maternal examination done at the same time

• internal examining fingers note the degree of descent while the thumb is placed over the symphysis pubis to note the degree of overlapping

• lack of descent and overlapping of the head and the symphysis points to severe disproportion

Pelvic inlet contraction

• anteroposterior diameter is less than 10 cms

• greatest transverse diameter is less than 12 cms

• Diagonal conjugate <11.5 cm

Midpelvic contraction

• the sum of interspinous diameter (10.5 cm) and the postero sagittal diameter of the midpelvis (5 cm) falls to 13.5 cm and below

• inter spinous diameter is less than 10 cms

• when smaller than 8 cms then definite contraction exists

• ischial bones are prominent

• sidewalls are convergent

• sacrosciatic notch is narrow

• more common than inlet contraction

• Management: midpelvic contraction is to allow the normal forces of the head beyond the are of narrowing

• use of oxytocin is contraindicated

Contracted pelvic outlet

• interischial tuberous diameter or less than 8 cms

• usually associated with midpelvis contraction and it is the combination of the two

• produces perineal tears

generally contracted pelvis

• all the different planes are shortened

• molding and internal rotation results in arrest in occipito posterior position due to associated mid pelvic contraction

• termination by cesarean section is usually done

Uterine abnormalities

• abnormal fusion of the mullerian ducts

• failure of absorption of the septum lead to a variety of congenital malformations of the uterus

  • broadening of uterine fundus

  • abnormal lie or presentation

  • history of repeated abortions

  • abnormal location of the cervix in the vaginal vault

Cervical abnormalities

• following extensive cauterization of the cervix, it may become so stenosed that dilatation and effacement may not take place during labor

• e.i. cervical stenosis, cesarean section is carried out

longitudinal septum

• septum that divides cervix to vulva

incomplete septum

• septum that divides upper or lower portion of vagina