Childbearing Exam 2

Critical Factors in Labor

• Passageway

• Passenger

• Position

• Physiologic Forces of Labor

• Psychosocial considerations

What is the passageway in labor?

• pelvis

• cervix

• vagina

• pelvic floor muscles

Gynecoid Shape

Android Shape

Anthropoid Shape

Platypelloid Shape

Passenger in Labor

• Head (fontanelles help determine position)

• Attitude

• Lie

• Presentation

What shape is the anterior fontanelle?

diamond

What shape is the posterior fontanelle?

triangle

What is the normal posture?

flexion (“fetal position”)

What is a fetus’ Longitudinal Position?

parallel to mother’s spine

What is a fetus’ transverse position?

perpendicular to mother’s spine

Types of Presentations

• cephalic

• breech

• shoulder

What is engagement?

occurs when the widest part of the baby's head passes down through the mother's pelvic inlet

What is station?

the level of the baby's head as it moves down through the mother's pelvis during pregnancy and labor

Ranges from -5 to +5

How is the fetal position written?

1st letter: R or L

2nd letter: landmark of presenting part

3rd letter: landmark is anterior, posterior, or transverse

Psychosocial Considerations

• hopes

• fears

• preparation

• support system

Signs of Impending Labor

• lightening

• braxton hicks

• cervical changes

• bloody show

• rupture of membrane

• burst of energy

First Stage of Labor

onset of labor & ends w/ full dilation

Phases of First Stage of Labor

Latent/Early: talking, excited, smiling

Active: discomfort & anxiety increase
Transition: restless & anxious; intense labor

Characteristics of True Labor

• progressive cervical dilation & effacement

• regular contractions

• frequency, intensity, & duration increase

• discomfort in back radiating to front

• walking is uncomfortable

• rest/warm bath doesn’t help

Characteristics of False Labor

• no cervical change

• irregular contractions

• no obvious increase

• discomfort in abdomen

• walking, rest, & warm bath help

Cardinal Movements of Labor

1. Descent

2. Flexion

3. Internal rotation

4. extension

5. restitution

6. external rotation

7. expulsion

Second Stage of Labor

cervix is fully dilated to birth of baby

• strong urge to bear down

• crowning

Third Stage of Labor

birth of baby to delivery of placenta

Signs of Placental Separation

• a rounded uterus rises in abdomen

• sudden gush of blood

• umbilical cord protrudes further from vagina

Fourth Stage of Labor

mom’s body adjust from delivery (4 hrs after)

• adjust to blood loss

• thirst & hunger

• chills

• uterus must contract

Maternal Response to Labor

• HR & BP increase during contractions

• supine —> sudden hypotension d/t vena cava

• hyperventilation + sweating —> dehydration

• polyuria

• solid food not absorbed

What is a toco?

a contraction monitoring device placed near the fundus

Ultrasound transducer

a monitor placed over fetal back to measure FHR

Intrauterine Pressure Catheter (IUPC)

placed in uterus to measure contraction frequency, duration, & intensity (more accurate)

Fetal Scalp Electrode

attached to fetal head to record FHR

Leopold Maneuver

a method to determine fetal position

Causes for Fetal Tachycardia

• maternal fever

• dehydration

• medications

• fetal prematurity, anemia, hypoxia

Causes of Fetal Bradycardia

• maternal hypotension

• head or cord compression

• fetal hypoxia

FHR: Baseline Variability

• Absent (non-reassuring)

• Minimal (<5 bpm)

• Moderate (6-25 bpm)

• Marked (26+ bpm)

FHR Accelerations

15 beats faster than baseline for 15 seconds = fetal movement & stimulation (OK)

FHR Early Decelerations

d/t pressure on fetal head (OK)

FHR Late Decelerations

d/t uteroplacental insufficiency (non-reassuring)

FHR Variable Decelerations

d/t compression of the umbilical cord (not concerning unless repetitive)

Category I FHR Tracing

Reassuring

• 110-160 baseline

• moderate variability

• no variable, prolonged, or late decels

Category II FHR Tracing

needs continual ax (not non/reassuring)

Category III FHR Tracing

Non-reassuring - immediate intervention

• absent variability

• late or variable decels

• bradycardia or sinusoidal pattern

Nursing Interventions for Abnormal FHR

Lie mom on her left side

Increase IV fluids

Oxygen (10 L/min) & stop oxytocin

Notify HCP

When to go to hospital

• membrane rupture

• decreased fetal movements

• regular, frequent contractions (5 / 6-8 min apart for 1 hr)

• vaginal bleeding

• consistent headache

Nursing Interventions for First Stage of Labor

• monitor vitals, contractions, FHR

• encourage walking, voiding

• vaginal ax PRN

• offer clear liquids

• breathing & relaxation techniques

• position

• hygiene

Nursing Interventions for Second Stage of Labor

• do not leave alone

• position for effective pushing

• explain sensations (BM, bear down, burning/splitting)

• monitor

Assisting with Delivery

• support perineum as bb crowns

• breathing exercises

• check for nuchal cord

• suction bb’s mouth & nose

• deliver anterior shoulder by pulling on head

Nursing Interventions for Third Stage of Labor

• newborn care (respiration & warmth)

• placental birth (oxytocin)

APGAR Scoring

• HR

• Respiration (crying)

• muscle tone

• reflex irritability (cry)

• color

Newborn Respiratory Rate

30 - 60 (no grunting, nasal flaring, or retractions)

Newborn Muscle Tone

flexed elbow & knees

Newborn Reflex Response

cry

Newborn Skincolor

pink, blue-tinged hands & feet

Nursing care at delivery

• weight

• ID baby & parents

• initiate attachment behaviors

• document

Nursing Interventions for Fourth Stage of Labor

• oxytocin

• sutures or local anesthesia for episiotomy

• clean perineum & ice

• reposition for comfort

• clean linen & warm blanket

Side Effects of Epidural

• hypotension

• instrument birth

• surgical birth

Side Effects of Inhaled Analgesia

• nausea

• vomiting

• dizziness

Methods to reduce pain of labor

• water immersion

• relaxation techniques

• acupuncture

• massage

• nonopioid medication

Systemic Sedatives

• for early/latent phase for relaxation & rest

• can lower APGAR score

Types of Systemic Sedatives

• benzo

• H1-receptor antagonist (promethazine HCL, benadryl)

Narcotic Analgesics (systemic)

• for stage 1/active phase

• to inhibit pain impulses

• side effects

  • resp depression

  • hypotension

Types of Narcotic Analgesics (systemic)

• fentanyl

• nuban

• morphine

Nitrous Oxide

• systemic analgesic

• safe, effective, inexpensive

• self-administered

Risks of Analgesics

• mild (vertigo, urinary retention, pruritis)

• moderate (N/V, hypotension)

• severe (systemic toxicity, bradycardia, respiratory depression, convulsions, cardiac arrest)

Precautions of General Anesthesia

• clear liquid diet

• NPO

• antacid (aspiration)

• tilt left

• patent IV line

Analgesic Considerations for preterm labor

• fetus doesn’t metabolize drug as much

• avoid analgesia & general anesthetics

Analgesic Considerations for Preeclampsia

• epidural is preferred

• hypo/HTN is more acute

Analgesic Considerations for DM

• vulnerable to poor placental blood flow

• hypotension can deplete blood flow to fetus

• use IV preload & tilt left

Signs of Preterm Labor

• pain in abdomen, back, or pelvis

• cramps

• ROM

• vaginal bleeding or discharge

• pelvic pressure

• urinary frequency

• diarrhea

Interventions for Preterm Labor

• bed rest

• cervical cerclage

• progesterone

• infection tx

• tocolysis

• corticosteroids (lung maturity)

Interventions for PROM

• prolong gestation to 34 wks

• infection prevention

• prevent umbilical cord prelapse

What is abruptio placentae?

premature separation of the placenta from the uterine wall

Risk factors of Abruptio Placentae

• previous hx

• HTN

• abd trauma

• fibroids

• overdistention of uterus

• alcohol

Marginal Placental Abruption

• separate at the edges of placenta

• dark red blood

• no abd pain

• fetal risk: preterm, anemia, hypoxia, brain damage

Central Placental Abruption

• at the center

• blood trapped behind placenta

• tender abd

• abd girth increases

• rigid, board-like abd

Complete Placental Abruption

• massive vaginal bleeding

• most severe - can lead to fetal death

• risk: hemorrhagic shock or disseminated intravascular coagulation

What is placental previa?

placenta is implanted improperly in lower uterine segment; can cover cervical opening

What is cervical insufficiency?

painless dilation of cervix w/o contractions d/t defect; can lead to repetitive loss or preterm birth

Intervention for cervical insufficiency

cerclage

Risk from Multiple gestation

• preg loss

• diabetes

• HTN

• HELLP syndrome

• PE

• preterm

• PROM

Oligohydramnios

less than normal amount of amniotic fluid

Risks of Oligohydramnios

• pulmonary hypoplasia

• formation of anomalies

• cord compression

Interventions of Oligohydramnios

• smaller fundal height

• amnioinfusion

• variable decel = common

Dystocia

abnormal labor patterns (power, passenger, passage)

Shoulder Dystocia

a delivery emergency where a baby's head is born, but one of the shoulders gets stuck behind the mother's pubic bone

Normal Contractions

3-5 in 10 min; relaxed for 1 min

Tachysystole

>5 contractions in 10 min; less than 60 secs between each contraction

Risk factors of Tachysystole

• oxytocin

• cocaine

• ROM

• placental abruption

Interventions for Tachysystole

• stop oxytocin

• empty bladder

• notify HCP

Hypotonic Labor

decreased frequency & intensity; slow progress of labor

Causes of Hypotonic Labor

• false or early labor

• induction w/ unripe cervix

• cephalopelvic disproportion

• passenger (macrosomia, malpresentation, malposition)

Interventions of Hypotonic Labor

monitor usual stuff & manage oxytocin

Causes of Post-term Preg

deterioration of placenta & fetus probs

• reduced blood supply

• decreased fetal O2

• reduced nutritional supply

Interventions of Post-term Preg

• non-stress test, biophysical profile

• assess estimated DOB

Common Fetal Malposition

occiput posterior (baby’s head facing mom’s spine)

Fetal Malpresentations

• military

• brow

• face

• breech

• transverse (shoulder)

Types of Breech Malpresentations

• Frank (flexed hips & extended knees)

• Footling (hips extended w/ foot presenting)

• Complete (flexed hips & knees)

Causes of Breech Malpresentation

• placenta implantation problems

• uterine & fetal anomalies

• multiple gestation

Risks of Breech Malpresentation

• umbilical cord prolapse

• head entrapment

• high morbidity & mortality