OB Cornell Notes Ch 14-16

Prenatal Yoga

• Helps relax and manage stress and overall fitness 

• Gentle stretching and deep breathing 

Perineal and Abdominal Exercises

• Exercises/Pelvic Floor contractions (kegels)/abdominal muscle contractions 

• Makes em stronger and more supple for labor 

• Also pelvic floor ctxns (kegel’s) and abdominal muscle ctxns.

Tailor Sitting

• Kinda like butterfly stretch

• One leg in front of the other (not cross ankles cus circulation); push knees down

• Sit for 15mins a day to allow perineum to become supple

Squatting

• Literally just squats

• Same idea as tailor sitting 

• Do it 15mins daily 

• Useful for second stage labor 

Pelvic Rocking

• Helps relieve backache during pregnancy early labor by making the lumbar spine more flexible 

• Done on hands and knees, lying down, or standing 

Birth Aids

• Activities used for distraction to displace feelings and thoughts around early labor symptoms 

• Playing cards, listening to specific music 

BRADLEY (PARTNER-COACHED) METHOD

Premise: pregnancy is joyful, natural process that partner should play active role in 

Reduce pain by abdominal breathing, encouraged to walk, use internal focus point to disassociate 

DICK-READ METHOD

Premise: fear -> tension -> pain, therefore prevent fear from occurring by achieving education on childbirth and focus on breathing 

PSYCHOSEXUAL METHOD

Premise: extension of Dick-Read; includes conscious relaxation, active calming of mind while discomforted, progressive breathing to flow rather than struggle; embrace them 

HYPNOBIRTHING

Help people focus on meditative practices during ctxns so they stay relaxed and free of fear.

LAMAZE PHILOSOPHY (gate control theory)

Premise: gate control theory of pain relief; stimulus response conditioning; use controlled breathing and stimulation (rubbing, massage, heat/cold) to reduce anxiety 

Components of labor

1. The passage (pelvis)

2. The passenger (fetus)

3. The powers of labor (uterine contractions)

4. The psyche (mental state)

The passage (pelvis)

The route a fetus must travel from the uterus through the cervix and vagina to the external perineum.

• If disproportion between fetus and pelvis occurs, pelvis structure is at fault 

• If presenting part is not its narrowest diameter, fetus is at fault 

The passenger (fetus)

• Body w/ widest diameter is head 

• 4 superior bones: frontal, biparietal, occipital 

• Fontanels spaces compress during birth to aid in molding; presence can be assessed for fetal position during labor 

• Biparietal diameter – smallest; anteroposterior diameter when fetus is in full flexion (chin to chest) 

• Fetal altitude, fetal lie, fetal presentation, and fetal position 

• Cardinal movement 

The powers of labor (uterine contractions)

Effective uterine ctxns have:

• rhythmicity

• progressive increase in length and intensity

• accompanying dilation of the cervix.

The psyche (mental state)

Those who manage best in labor typically have a strong sense of self esteem and a meaningful support person

complete flexion

Optimal fetal attitude; the head flexed forward so much that the chin touches the sternum (vertex). This occupies the smallest space possible.

fetal lie & presentation

Fetal Lie = How the baby is oriented relative to the mother's body (head-to-toe direction)

• Longitudinal lie: Baby is aligned head-to-toe with mother (normal, most common)

  • Cephalic: Head down (vertex presentation) — ideal for vaginal delivery

  • Breech: Buttocks/feet down

• Transverse lie: shoulder down — Baby is sideways across the uterus

fetal position

The relationship of the presenting part to a specific quadrant and side of the pregnant person’s pelvis. In a vertex presentation, the occiput (O) is the chosen point. If the occiput of a fetus points to the left anterior quadrant, the fetal position is LOA the most common fetal position. Fetus in these positions are born the fastest: LOA>ROA 

Labor can be extended if the position is posterior (ROP or LOP) and may be more painful because the rotation of the fetal head puts pressure of the sacral nerves. 

_OA = good 

_OP = pain 

Engagement

refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines the midpoint of the pelvis.

Station

is the relationship of the presenting part of the fetus to the level of the ischial spine.

0 station

when the presenting part is at the level of the ischial spine

-1 to -4 cm

if above the ischial spine

+1 to +4 cm

if presenting below the ischial spines

+3 station

crowning; the presenting part can be seen at vulva

False contractions

Benign and remain irregular

Felt first abdominally + remain confined to abdomen and groin

Often disappear with ambulation/sleep

Do not increase in duration, frequency, or intensity

Do not add cervical dilation

True contractions

Begin irregularly but become regular and predictable

First felt in lower back, sweeps to abdomen

Continues no matter activity level of PT

Increases in duration, frequency, and intensity

Achieve cervical dilation

First stage of labor

• takes abt 12hrs

• 3 segments: latent, active, transition 

• Latent: from 0-5cm dilated, contractions mild n last ~30s 

• Active: 6-7cm, cervical dilation occurs more rapidly, contractions ~60s and q3-5mins 

• Transition: contractions reach peak intensity 8-10cm dilated, pt in intense discomfort, may have n/v, lose control & modesty, irritable 

latent

from 0-5cm dilated, contractions mild & last ~30s 

active

6-7cm, cervical dilation occurs more rapidly, contractions ~60s & q3-5mins

transition

contractions reach peak intensity 8-10cm dilated, pt in intense discomfort, may have n/v, lose control & modesty, irritable

Nursing care during 1st stage

• Empower birthing parent 

• Respect contraction time 

• Promote position changes 

• Help fetal alignment (squatting or being on all fours may help) 

• Promote voiding; bladder care, void q2hrs during labor 

Second stage of labor

• Pushing stage 

• Full dilation and cervical effacement to birth of infant 

• Fetal head pushed out of birth canal; extends then rotates to bring shoulders into best line with pelvis 

• Body of baby then born 

Nursing care during 2nd stage

• Encourage PT to be in comfy position and breathe any way that is natural 

• danger of Chorioamnionitis – infection of membrane; increases likelihood of c-section (danger of prolonged second stage) 

• Baby born; cut cord and clamp 

Third stage of labor

• Placenta stage 

• Begins with birth of infant, ends with delivery of placenta, placental separation, and placental expulsion 

• 1-30mins (normal) 

Nursing care during stage 3 + 4

• If pt uterus has not contracted back to normal, massage fundus to encourage 

• Oxytocin to help with contraction

• If excessive bleeding with poor uterine contractions, administer IM hemabate or methergine (responsibility: no contraindications like HTN or asthma) 

Signs of placental separation

• Signs placenta has loosened + ready to deliver (think of placenta like a scab) 

• Lengthening of cord 

• Sudden gush of blood from vagina 

• Placenta visible at vaginal opening 

• Uterus contracts and feels firm again 

Maternal Danger signs of labor: 

• Gestational HTN, >140/90

• LBP (+ elevated HR = possible hemorrhage) 

• Abnormal pulse >100bpm (possible hemorrhage) 

• Inadequate ctxns: (potential uterine exhaustion) 

• Prolonged contractions (could compromise fetal well-being because it interferes with adequate uterine artery filling) 

• Abnormal lower abdominal contour (full bladder you will see bulge, however full bladder may not allow fetal head to descend and bladder may be injured by fetal head; pee q2hrs) 

Fetal Danger signs of labor: 

• High/Low fetal HR (110-160bpm norm) 

• Meconium staining (stressed baby in womb; indicative of hypoxia; REPORT) 

• Hyperactivity; frantic movement (sign of hypoxia) 

• Low O2 sat (<40% needs further assessment) 

Auscultation of the fetal heart sounds:

In a vertex presentation, fetus heart sounds are best heard through the fetal back. 

In cephalic presentation, they are heard loudest low in the patient’s abdomen. 

Assessing FHR involves 3 parameters:

Fetal HR baseline, variability, periodic changes

Fetal HR

110-160bpm

Accelerations

+15bpm for 15s, normal inc from fetal movement, change in maternal position, or analgesic

Early decelerations

Normally occur late in labor when fetal head is descended; innocent

Late decels

onset, nadir, and recovery occur after the beginning, peak and ending of the ctxn, respectively.  It suggests utero-placental insufficiency or decreased blood flow to fetus.

Nurse action: immediately change PT position to lateral, O2, IV

Prolonged decels

sustained drop in HR, may indicate cord compression or maternal HoTN

Variable decels

Unpredictable, abrupt drops. May indicate cord compression. Tends to happen after rupture of membranes.

Nurse action: change PT position to lying on lateral. If cord prolapse: O2 and knees to chest position

ACOG FHR categories

Category I (Normal):

• Baseline and variability normal

• Action: Continue routine monitoring ✓

Category II (Indeterminate):

• Some abnormal findings, unclear significance

• Action: Keep watching, reassess regularly

Category III (Abnormal):

• Clear problems (late decels, absent variability, etc.)

• Action: Urgent intervention — change position, O2, IV, stop labor stimulation

• If doesn't improve → deliver baby now

In short: I = good, II = watch closely, III = act fast or deliver

Pharmacologic Measures for Pain Relief During Labor

When labor is in the active phase of the first stage, analgesic meds tend to speed up labor. In contrast, in the 2nd stage of labor, epidurals can slow progress and result in more instrumentation or cesarean births. 

Opioid (Narcotic) Analgesics 

Causes resp depression and fetal CNS depression so timing is important!  

• Given too early (< 3 cm) will slow labor 

• Given too close to birth will lethargic sleepy baby 

• Preferably given when pt is >3hrs from birth so the newborn can breathe easily 

Common opioids

Nubian, sublimate, stadol, demerol

• narcan should be available to give to the infant at birth PRN

Regional (local) Anesthesia 

Benefits:

• Completely eliminates pain

• Mother awake and aware during birth

Main risk: Hypotension

• Treatment: Raise legs, IV fluids, O2

Disadvantage of epidural:

• Reduces pushing reflex/effort

• Delays fetal descent

• Prolongs 2nd stage labor

• Increases need for instrument-assisted delivery (forceps/vacuum)

Nursing actions for prolonged 2nd stage labor

• change positon (all fours)

• let epidural wear off by 2nd stage

• oxytocin IV

Aftercare for epidural pt

Position to prevent hypotension:

• Lie on side OR

• On back with firm towel under left hip

Bladder care:

• Epidural numbs sensation → pt can't feel bladder fullness

• Nursing action: Remind to void every 2 hours