OB Labor and Delivery

What is labor?

• Rhythmic uterine contractions of enough frequency, intensity, and duration, to change cervical dilation, effacement, causing fetal decent/delivery

What are Braxton Hicks?

• Preterm labor/contractions

• Painful, can feel like real deal

• Not going to dilate/efface the cervix

When should labor start?

• After 37 weeks

• Before 37 weeks = preterm

What are the 5 P’s of labor?

• Passenger (baby)

• Passageway (bony pelvis and soft tissues)

• Power (uterine contractions)

• Position (of the mother)

• Psychological response (of mother)

How many stages of labor are there?

• 1st, 2nd, 3rd, 4th

What are the different ways labor can start/progress?

• induction

• Augmentation

• Spontaneous

**tools and medications used

What assessments are there during labor?

• Cervical/Vaginal Exam (VE), FHR Assessment, Contractions

What does passenger (baby) entail?

Look at:

• Size of fetal head

• Attitude (can impact diameter of baby’s head as it’s coming through)

• Fetal lie: longitudinal or vertical (can not deliver vaginally)

• Fetal presentation

• Position AKA “Station”

• “Engagement”

What are the different attitude presentations?

• A = Vertex: Most common/most ideal, smallest diameter, chin flexed to chest. Occiput (back of fetal head) is presenting part (think about baby pouting), they are lined up perfectly to come out

  • With positioning we want to try and get baby into this position for delivery

• There are also B = Occipitofrontal, sinciput presentation, C = Brow presentation (largest diameter) and D = Face presentation

What is fetal presentation?

• Relationship of presenting part to the 4 quadrants of maternal pelvis Fetal presentation (body part entering pelvis first: breech, cephalon-vertex or shoulder)

• Ideally want the occiput of baby’s head to be in an anterior (right or left) position in moms pelvis, baby facing moms spine

• Can deliver w/baby’s occiput in a posterior position in moms pelvis but will be a tighter fit and can cause mom more pain

• Baby can also be in transverse position, completing facing R or L hip

How do you abbreviate fetal presentation?

• 3 letter abbreviation includes:

  • 1. Described as Right or Left side of maternal pelvis (R or L)

  • 2. Specific presenting part

  • 3. Location of presenting part: anterior, posterior, transverse

  • Ex’s: ROA- Right occipitoanterior, LOP- Left occipitoposterior, ROT- Right occipitotransverse

What is position AKA “Station”?

• How far down is the baby into the maternal pelvis?

• Relationship between the presenting part to an imaginary line between the ischial spines of the maternal pelvis

• -3 = at the pelvic inlet

• 0 = engaged in pelvis, “station”- fetal vertex is at the level of the ischial spines

• +3 = at the pelvic outlet

**negative = baby is high, positive = baby is coming out

What is “Engagement”?

• Occurs when the largest diameter of the presenting part reaches or passes through the pelvic inlet and is at the level of the ischial spines

• Once widest part of baby’s head reaches position 0 (station) they are engaged

**Positions can encourage engagement

What are the different parts of a cervical exam?

• 1st: dilation

• 2nd: effacement

• 3rd: station

What are the 4 different pelvic types that fall under passageway?

• Gynecoid (round, 50% of women have this), this is ideal and most favorable for vaginal delivery!!

  • Someone w/o this can still deliver it will just be more difficult

• Android (heart, 23%)

• Anthropoid (oval, 24%)

• Platypelloid (flat, 3%) → probably c-section

**internal shape of pelvis determines if a baby can fit through, not external size of hips

What is the cervix able to do during labor?

• Opening of uterus

• Should have ability to dilate (opens) and efface (thins)

• Typically you want it to thin before it dilates

What is the birth canal able to do during labor?

• Has the ability to distend/stretch to accommodate for baby to come through

• Genital warts or scar tissue can affect this

What is Cephalopelvic disproportion (CPD)?

• Happens when baby cannot pass through the birth canal bc there is a mismatch in size or shape → Baby’s head or body is too big to fit though mom’s pelvis

• Baby with bad attitude (brow presentation) presenting w/ a wider head diameter → can lead to CPD

What are the different maternal positions?

• Inlet opener to help baby engage

• Midpelvis opener for fetal rotation

• Laboring down: Outlet opener to help with pushing

**one of the biggest this we can do as nurses to help with progression of labor

What is the inlet opener position?

• For high fetal stations -3, and -2 → focusing on opening the inlet (top of pelvis)

• Ball between knees (external rotation of femur) + hips fully extended (posterior pelvic tilt)

• “Flying cowgirl”

What is the midpelvis opener position?

• For fetal rotation

• For fetal stations -1, 0, and +1 → focus on opening the midpelvis (center)

• Getting legs to be asymmetrical, one up, one down

• Ball under entire shin (uneven hip) + Roll towards belly (side lunge movement) + Bottom leg kicked back (uneven and sideways)

What is the laboring down position?

• Outlet opener to help with pushing

• When baby is low in pelvis, for fetal stations +2 and +3 → focus on opening the outlet (time to push!)

• Ball between ankles (internal rotation of femur) + knees forward for a neutral spine and sacrum space

What is the Power of uterine contractions?

• Primary powers-involuntary: Contractions (what our body does based on signals of oxytocin)

• Secondary powers-voluntary: Bearing down/Pushing

What is Ferguson’s Reflex?

• Secondary- involuntary power/reflex: activated when baby’s head pushes against nerves in the bottom of the vagina/pelvic floor

• This is involuntary pushing reflex

• Epidural can partially or completely block this by numbing the nerves that trigger the involuntary urge to push

What is the psychological response of the mother?

• Labor = positive feedback loop

• Brain stimulates pituitary gland to secrete oxytocin (spontaneously) → Oxytocin travels to uterus via the bloodstream → Oxytocin amplifies uterine contractions → Uterine contractions push baby’s head against the cervix → back to beginning

  • Can give synthetic oxytocin (Pitosin) in which the brain is not stimulating gland

How does a contraction work to open cervix?

• Pulling action: The upper part of the uterus has muscle fibers that shorten and pull upward during a contraction which pulls the lower muscle fibers and the cervix up and back making it shorten and stretch

• Pushing action: As the top of uterus tightens, it pushes baby downward, the baby’s head presses firmly against inside of the cervix that helps force the opening wider

How does stress affect labor?

• stress during labor may lead to increased production of cortisol, which interferes with the production of oxytocin

What is cervical ripening?

Used when cervix is not ready and we need to soften, thin, and open the cervix before labor induction

• Mechanical: Catheter

  • Cooks catheter (can also use a normal catheter): two balloons, it is mechanically squishing the cervix so that it thins out

  • First time mom w/thick cervix can be put on Pitocin to contract but it isn’t effaced so she probably won’t dilate so we have to get the cervix thin before we get it open

• Chemical: Cytotec (misopristol)

  • Off label medication

  • Used to induce labor, meant to soften cervix

What is induction?

• Convincing the uterus to do something it’s supposed to do on its own

  • Intravenous Pitocin administration is #1 way to do this and stimulate contractions

  • Sometimes they can break the bag of water water (amniotomy) and it will start the positive feedback loop and get everything going

  • Both of these ways can also be use to augment labor (help things along), when things start to stop and slow down or contraction

What is Stage 1 of labor?

• When true labor starts to completely dilated (10cm)- at 10cm cannot feel cervix at all when doing a cervical exam

• Has 2 phases:

  • Latent/early phase

  • Active phase

What is the latent/early phase of stage 1 labor?

• Uterine contractions established, increase in frequency, duration, intensity

• Begins as mild contractions; progresses to moderate

• Excitement, able to walk/talk through most UC’s

• Cervix dilates 0-5 centimeters

• Nulliparous (first time mom)/multiparous (not first time mom) women progress similarly

What is the active phase of stage 1 labor?

• Fears loss of control

• Decreased ability to cope; irritable

• May have N/V

• Cervix dilates from 6 to fully dilated/effaced

  • Uncontrollable shivering (Transition 8-10cm)

• Fetal decent is progressive

• Multiple progress more quickly

What is stage 2 of labor?

• When they start pushing through birth of baby

• Has 2 phases:

  • Latent/passive phase

  • Active pushing phase

What is the latent/passive phase of stage 2 labor?

• “Laboring down”

• Period of rest/calm

• Passive decent occurs

• During this the cervix is 10cm dilated but we haven’t started pushing and are going to let body keep working

What is the active pushing phase of stage 2 labor?

• Strong urge to push (epidural minimizes this, will likely still feel pressure)

• 1 push to 3+ hours

What is stage 3 labor?

• birth of the baby through delivery of placenta

• Uterus contracts firmly

• Potentially see signs of placental separations

• Providers do “gental” active 3rd stage management → pulling on umbilical cord to test if there is give, does it want to come yet?

What are sings of placental separation?

• Rise of fundus in the abdomen (shape of abdomen changes)

• Sudden gush or trickle of blood

• Lengthening of umbilical cord (more protruding out of vagina)

What is the number one nursing concern IMMEDIATELY after delivery of the placenta?

• Managing postpartum bleeding

• We want uterus to clamp down in near constant contraction

  • Can be done with medication or massage

What is stage 4 of labor?

• Delivery of the placenta until mom is stable (~1-2hrs)

• Physiological readjustment

• Hemodynamic changes: huge volume of blood that isn’t circulating, watching BP closely

• Quantitative Blood Loss (QBL)- you weigh the blood

• Shaking/Chills

• Dizziness and syncope

What should the RN assess at stage 4 of labor?

• fundus, lochia, bladder, pain

What is normal vaginal vs c-section quantitative blood loss?

• Vaginal (<500) → >500 = hemorrhage

• C-section (<1000) → >1000 = hemorrhage

What can nurses do to support labor?

• Encourage participation of pt and partner

• Educate pt/partner about surroundings, plan of care, interventions, etc.

• Gain pt/partner families’ story-What can you do to best care for them? What are the desired wishes during labor? Clarify who is in the room and their roles

• Advocate by listening, timely follow up, nonjudgmental care

  • Keep in mind that mom is the decision maker (her decisions come 1st and they may change)

• Encourage self care (eating, staying hydrated, resting, etc.)

• Acknowledge strengths and stressors

What does PAIN stand for?

• Purposeful

• Anticipated

• Intermittent: they get a break, pain during contractions and then relax/rest during contractions

• Normal

What are pain management strategies for labor?

• Anxiety/breathing techniques

• Heat/Hydrotherapy

• Counter pressure

• Nitrous Oxide

• IV narcotics

• Epidural/Spinal (c-section)

What are some nursing interventions for epidural placement?

• Epidurals numb about everything from mid abdomen down??

• Everything that gets numb vasodilates → think hypotension

  • Common drop in BP after an epidural

  • Provide fluid bonus 500-1000 mL of IV fluids during epidural administration to up blood volume temporarily

How do you assess progression of labor?

• Cervical check/Vaginal exam (VE):

  • Dilation

  • Effacement

  • Station

What is Dilation?

• The opening of the cervix

• Documented in measurements of 0-10 centimeters

What is effacement?

• The thinning of the cervix

• Documented in measurements of 0-100%

• Changes progressively from long to paper thin (Thinner is stretchier)

What is station?

• The location of the presenting part in relation to the maternal pelvis

• 0 = ischial spines

• -1 to -3 = above ischial spines

• +1-+3 = below the ischial spines

What is 3/90/+1 and 10/100/+3 in terms of a cervical check/vaginal exam?

• 3cm dilated, 90% effaced, +1 station

• 10cm dilated, 100% effaced, +3 station

What is a perineal laceration?

• tissue tears as baby exits moms body

What is an episiotomy?

• Providers can choose to make an incision (midline or medio-lateral) based on assessment of if the tissue is going to stretch anymore or if it will tear

What is a 1st degree tear?

• Superficial tear involving the perineal skin and vaginal mucous membrane

What is a second degree tear?

• Moves into the fascia and muscles of perineal body, may extend upward on one or both sides of vagina

What is a third degree tear?

• Extending through the perineal skin, vaginal mucous membranes and involves the anal sphincter

What is a fourth degree tear?

• Extends all the way through anal sphincter and into the rectal mucosa

What are some indications for a c-section deliver?

• Failure to descend (FTD)

• Fetal intolerance to labor (FITL)

• Cephalopelivic disproportion (CPD)

• Placenta problems (previa-not attached/abruption)

• Maternal request

• Multiples

What is part of nursing care for a c-section?

• Pain management- narcotics, binder (counter pressure), ice

• Increased DVT risk- ambulation- SCD

• Blood loss risk

• Infection risk

• Birth trauma (emergent/unplanned)

What tools are used for external monitoring?

• Ultrasound transducer for Fetal Heart Rate (FHR)- top belt

  • High frequency sound waves to pick up mechanical motion of fetal heart valves opening and closing

  • Gives FHR on top of strip

• Tocotransducer (TOCO) for contractions

  • Pressure sensitive button that sits on fundus, uterus contracts and pushes on the TOCO

  • Measures frequency of contractions and the duration of a single contraction (NOT how strong the contraction is)

  • The Mountain peaks (strength) depend entirely on where the belt is sitting, how tight the belt is on, and adipose tissue (just a yes or no if a contraction has happened)

How do you measure a contraction with palpation?

• Mild = nose (firm but easily indentable)

• Moderate contraction = chin (has give but undeniable resistance)

• Strong contraction = forehead (hard unyielding bone)

What tools are used for internal monitoring?

• Internal fetal spiral/scalp electrode (FSE) for fetal heart rate (FHR) → internal heart monitor (if ultrasound transducer isn’t working, goes directly onto baby’s scalp, gives electrical active of fetus’s heart, invasive, water must be broken)

• Intrauterine pressure catheter (IUPC) for contractions (inserted directly into the amniotic space by the fetus), measures hydrostatic pressure inside the uterus to measure contraction strength ((reserved when external monitoring isn’t giving what you need)

• RN may place with training and if allowed by facility policy

What are you considering for fetal heart rate?

• Baseline: increments of 5 BPM, average BPM during a 2-minute period of time

• Variability: absent, minimal, moderate, marked

• Accelerations

• Decelerations: early, variable, late, prolonged

VEAL CHOP MINE Mnemonic

• FHR Pattern (VEAL): V- variable deceleration, E- early deceleration, A- acceleration, L- late acceleration

• Cause (CHOP): C- cord compression, H- head compression, )- Okay!, P- placental insufficiency

• Management (MINE): M- maternal repositioning, I- identify labor progress, N- no interventions, E- execute interventions

What is baseline for FHR?

• Normal: 110-160 bpm

• You must evaluate a 10min window and there must be a minimum of 2min of identifiable baseline segments

  • If you can’t do this, it is called an intermediate baseline

• A fetal heart has a very small stroke volume so to maintain CO it has to pump faster

What is fetal tachycardia?

• >160 bpm sustained for 10min or more (look at moms HR for maternal explanation)

  • Maternal fever, pain, infection, meds

  • Fetal hypoxia

  • Fetal anemia

What is fetal bradycardia?

• <110 bpm (once passes 10min it becomes a baseline instead of deceleration)

  • Fetal cardiac issue? (Heart block?)

  • Prolonged compromised placental perfusion

When looking at FHR variability what are the different categories?

• Absent: “visually undetectable” (no one is flying plane, nervous system is depressed)

• Minimal: <5 bpm (pilot is nodding off, baby could simply be in normal sleep cycle, not always bad)- watch like a hawk, if passes 2hrs no longer sleeping baby

• Moderate: 6-25 bpm (pilot making tiny micro adjustment to steering), ultimate proof of neurological life

  • Reassurance in the moment that baby is doing well, not guarantee it will last

• Marked: >25 bpm (cannot determine FHR BL)- pilot not in control/panicking, often indicates nervous system working way too hard and warning sign things will get worse

What is the holy grail, main determinate of fetal monitoring??

• Variability!!

  • Tells how baby is doing IN THE MOMENT

What are accelerations?

• Jumps in HR

• 15bpm above baseline with a duration >15 secs but <2min

• Same thing as moderate variability but louder, requires intact somatic and autonomic nervous system, shows oxygenation

• Absence doesn’t require panic as long as moderate variability is there

What are early decelerations?

• Early drops in HR

• Early deceleration = U shape

  • Takes 30sec or > for HR to drop from baseline to lowest point (nadir)

  • The nadir of the decel and the peak of the contraction match in timing (pressure of contraction causes HR to drop)

  • Usually means baby is moving down birth canal and baby is progressing nicely

• Early deceleration → head compression → identify labor progress

• MECHANICAL REFLEX

What is variable declerations?

• Wild card!

• Abrupt (violent V shape) onset to nadir <30sec, with drop of 15bpm below baseline for > or equal to 15 secs but < 2min

• Stepping on a water hose, once stepped off pressure returns

• Can happing during, between, or just bc baby rolled over

• Variable deceleration → cord compression → maternal repositioning (move mom to move baby)

What are late decelerations?

• Bad guys!!

• Takes 30 sec or more to bottom out

  • Nadir of HR happens after peak of contraction, sometimes it is over (like baby is on a lag, chemical delay)

  • Onset, nadir and recovery of deceleration follow beginning, peak and end of contraction

• Late declarations → placental insufficiency (contraction squeezes blood vessels completing squeezing off blood to baby) → execute interventions (requires immediate action to restore oxygen to fetus)

• METABOLIC CRISIS

What is prolonged deceleration?

• Deceleration is > or equal to 15bpm and > 2min but <10min

• Longer than 10min becomes fetal bradycardia

• Baby is essentially holding its breath and clock is ticking

What do the categories describes?

• ONLY talking about FHR/fetus NOT contractions

• Fetus could look great on paper, but mom is not doing well with contractions

What is category 1 for FHR tracings?

• Gold standard, baby thriving

• Criteria:

  • Baseline FHR: 110-160 bpm

  • Baseline FHR variability: moderate

  • Late or variable decelerations: absent

  • Early decelerations: present or absent

  • Accelerations: present or absent

What is category 2 for FHR tracing?

• Everything else, anything not met in category 1 or in category 3

• Trend is everything with this, look at narrative arch over time

What is category 3 for FHR tracing?

• Red alert!

• Visual undeniable proof of that fetal compensatory mechanisms have failed

• Criteria:

  • MUST HAVE absent baseline FHR variability combined WITH recurrent late decelerations OR recurrent variable decelerations OR bradycardia

  • Can also JUST HAVE Sinusoidal pattern (rare) → typically caused by profound anemia (RHisoimmunization)

What are the 3 categories for assessing contractions?

• Frequency: beginning of one contraction to the beginning of the next

• Duration: beginning of contraction to the end of the same contraction

• Intensity: strength of the contraction

  • pain rating, palpate abdomen during and in between contractions (resting tone), mild, moderate, strong/firm

What is the sink analogy?

• The placenta is a reservoir… think of it as a sink of oxygenation

  • The baby is always emptying the sink with every heartbeat, taking more oxygen (the drain)

  • The mom’s blood perfuming the placenta is the faucet

  • Perfusion to the placenta slows during contraction (slower faucet)

  • Perfusion to the placenta should be wide open when no contractions are present

What is Tachysystole regarding contractions?

• >5 UCS in 10min averaged over 30min

• The uterus is contracting too frequently, leaving insufficient time for the uterine muscle to relax between contractions.

• Sink (placenta) never has time to refill and oxygen level in the sink (placenta) gets lower and lower

  • Why it can be deadly and a medical emergency

What is resting tone regarding contractions?

• The pressure or tension in the uterus between contractions, when the uterine muscle is relaxed

• It is measured in mmHg when an intrauterine pressure catheter (IUPC) is used.

• This is important bc it allows the uterine muscle to relax between contraction, gives the placenta time to restore blood flow and deliver oxygen to the fetus, prevents excessive uterine pressure, helps assess whether contractions are too frequent