[OB FINAL] 1/5 (Exam 1 Content)

5 P’s of Labor Explained in 5 Minutes

Gynecoid: Pumpkin shape (best prognosis)

Anthropoid: Human-face shape (decent prognosis)

Android: Alien-face shape (poor prognosis, leads to C/S)

Platypelloid: Flat shape (poor prognosis, leads to C/S)

“We love to give birth to PUMPKINS (BABIES) and ANTHROS/HUMANS, not ANDROIDS/ALIENS and PLATYPUSES”

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Passageway (aka highway)

• Presentation: Body part reaching inlet first

• Lie: Spinal axis relationship

• Attitude: Flexion (Angry!) vs Extension (Excited!)

• Position: Pelvis spine axis relationship (LOA, LOP, etc)

• Station: How far down birth canal and which part

Passenger (fetus and placenta)

Powers (UCs: Duration, Frequency, Intensity)

Position (Maternal adjustments)

Psyche (Maternal Emotions)

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https://www.youtube.com/embed/LaVeU99q3WI

Performing Leopold’s Maneuvers

1st: Check for baby’s head/butt

• Form triangle, face mom’s face, feel fundus

  • Head = Firm, hard, moves independently

  • Buttocks = Squishy, moves with body

2nd: Check for baby’s back

• Press lateral side of abdomen

  • Back = Flat, long, firm, smooth

  • Extremities = Small, bent

• Side where fetal heart monitor placed (most accurate)

3rd: Check if baby part (e.g., head) is in pelvic outlet (engaged)

• Form L, place near symphysis pubis, try lifting baby’s part up (e.g., head)

  • Cannot lift baby head = engaged

  • Can lift baby head = not engaged

4th: Check for baby’s position (cephalic prominence)

• Face mom’s feet, palpate upward lateral sides of abdomen

  • Expected: Brow (cephalic prominence) on opposite side of back

Not always used d/t ultrasounds on most units

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https://www.youtube.com/embed/5K-ERuVrvj4?si=EaxldjGDVvR9gadf

Delineate the procedure for performing Leopold’s maneuvers and the information obtained.

1st Leopold Maneuver

Checks for baby’s head/butt

• Form triangle, face mom’s face, feel fundus

  • Head = Firm, hard, moves independently

  • Buttocks = Squishy, moves with body

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Determines shape, size, consistency & mobility of presenting part

2nd Leopold Maneuver

Checks for baby’s back

• Press lateral side of abdomen

  • Back = Flat, long, firm, smooth

  • Extremities = Small, bent

• Side where fetal heart monitor placed (most accurate)

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Determines fetal back & side.

3rd Leopold Maneuver

Checks if baby part (e.g., head) is in pelvic outlet (engaged)

• Form L, place near symphysis pubis, try lifting baby’s part up (e.g., head)

  • Cannot lift baby head = engaged

  • Can lift baby head = not engaged

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Determines what fetal part is lying above the pelvic inlet

4th Leopold Maneuver

Checks for baby’s position (cephalic prominence)

• Face mom’s feet, palpate upward lateral sides of abdomen

  • Expected: Brow (cephalic prominence) on opposite side of back aka flexion

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Determines fetal attitude (extension vs flexion)

Stages of Labor (Image)

First Stage

• Phases:

  • Latent/Early Phase (0-5 cm):

    • Contractions: Irregular, mild to moderate

      • Frequency: 2-30 minutes apart

      • Duration: 30-40 seconds

    • Maternal Characteristics:

      • Scant brownish or pink discharge, mucus plug

      • Talkative or calm, focused on labor and baby

      • Able to walk through contractions, follows directions

      • May feel apprehension

  • Active Phase (6-10 cm):

    • Contractions: More regular, moderate to strong

      • Frequency: 1.5-5 minutes apart

      • Duration: 40-90 seconds

    • Maternal Characteristics:

      • More intense emotions (anxiety, helplessness)

      • Pain feels severe, may feel out of control

      • Nausea, vomiting, rectal pressure, urge to push

      • Increased blood flow

      • Considered the most difficult part of labor

Second Stage

• Key Features:

  • Full dilation (10 cm)

  • Pushing and fetal descent

  • Results in the birth of the baby

• Maternal Characteristics:

  • Active pushing

  • Feelings of exhaustion and determination

Third Stage

• Key Features:

  • Delivery of the placenta

  • Placental separation:

    • Schultze Presentation: Shiny fetal surface of the placenta comes out first

    • Duncan Presentation: Dull maternal side of the placenta emerges first

Fourth Stage

• Key Features:

  • Maternal stabilization of vital signs

  • Goal: Achievement of homeostasis

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Compare and contrast the physiologic and psychologic changes occurring in each of the stages of labor.

Chapter 11/14 Hiighlights

QPCC

• An intrapartum nurse should  assess maternal and fetal well-being during labor, including determination of labor, the progress of labor, and psychosocial and cultural factors that affect labor.

• Promote baby-friendly activities between the family and the newborn, which facilitates the release of endogenous maternal oxytocin. Examples of such activities include introducing the parents to the newborn  and facilitating the attachment process by promoting skin-to-skin contact immediately following the birth. Allow private time and encourage breastfeeding.

QS

• Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse. 

• Group B streptococcus: Culture is obtained if results are not available from screening at 36 0/7-37 6/7 weeks for screening patients.. If positive, an intravenous prophylactic antibiotic is prescribed

• Resting tone of uterine contractions: Tone of the uterine muscle in between contractions. A prolonged contraction duration (greater than 90 seconds) or too frequent contractions (more than five in a 10-min period) without sufficient time for uterine relaxation (less than 30 seconds) in between can reduce blood flow to the placenta. This can result in fetal hypoxia and decreased FHR.

• When there is suspected rupture of membranes, first assess the FHR to ensure there is no nonreassuring fetal status caused from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid. 

• During Stage 4, massage the uterine fundus and/or administer oxytocics to maintain uterine tone and to prevent hemorrhage

First Stage of Labor (1 of 4)

1. Latent/Early Phase (0-5 cm):

   • Contractions: Irregular, mild to moderate

     • Frequency: 2-30 minutes apart

     • Duration: 30-40 seconds

   • Maternal Characteristics:

     • Scant brownish or pink discharge, mucus plug

     • Talkative or calm, focused on labor and baby

     • Able to walk through contractions, follows directions

     • May feel apprehension

2. Active Phase (6-10 cm):

   • Contractions: More regular, moderate to strong

     • Frequency: 1.5-5 minutes apart

     • Duration: 40-90 seconds

   • Maternal Characteristics:

     • More intense emotions (anxiety, helplessness)

     • Pain feels severe, may feel out of control

     • Nausea, vomiting, rectal pressure, urge to push

     • Increased blood flow

     • Considered the most difficult part of labor

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Two phases

Latent/Early Phase Main Characteristics (1st Stage)

0-5 cm dilation

UC Q2-30, 30-40 secs

Talkative or calm

Able to walk and follow directions

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Educate breathing techniques

Assess cervical dilation, pain, maternal/fetal condition

• IV pain medication usually administered

Active Phase Main Characteristics (1.5 Stage)

6-10 cm dilation

UC Q1.5-5, 40-90 secs (strong)

Intense emotions (anxious/scared)

PAIN, N/V, Pressure, Urge to Push

Second Stage of Labor (2 of 4)

Key Features:

• Begins with full dilation (10 cm)

• Pushing and fetal descent

• Ends with the birth of baby

Maternal Characteristics:

• Active pushing

• Feelings of exhaustion and determination

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Ensure sterile room, equipment, supplies

Prepare radiant heat warmer and neonatal emergency equipment

Continue assessing fetal/maternal VS and condition

Support mother’s bearing down efforts

Third Stage of Labor (3 of 4)

Key Features:

• Begins with birth of baby

• Ends with the delivery of placenta

• Placental separation:

  • Schultze Presentation: Shiny fetal surface of the placenta comes out first

  • Duncan Presentation: Dull maternal side of the placenta emerges first

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Oxytocic medications available AFTER expelling placenta

• Prevents Postpartum Hemorrhage (PPH)

  • Uterus must contract and narrow open blood vessels where placenta was attached

• Ensures Complete Placental Expulsion

  • Uterus can contract strongly and expel any remaining placental fragments

• Prevents Trapping the Placenta (aka retained placenta)

• Promotes Uterine Recovery (prevents atony)

Why are oxytocic (uterine contraction) medications given AFTER stage 3 (placental delivery)?

Prevents Postpartum Hemorrhage (PPH)

• Uterus must contract and narrow open blood vessels where placenta was attached

Ensures Complete Placental Expulsion

• Uterus can contract strongly and expel any remaining placental fragments

Prevents Trapping the Placenta (aka retained placenta)

Promotes Uterine Recovery (prevents atony)

Fourth Stage of Labor (4 of 4)

Key Features:

• Maternal stabilization of vital signs

• Goal: Achievement of homeostasis

Factors Affecting the Delivery

Fetus

• Size

• Position

• Presentation

Mother

• Adequate pelvis size

• Contractions

• Pushing effort

Other

• Maternal anesthesia

Premonitory

(adjective) something gives a warning or feeling that something unpleasant is going to happen

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Premonitory signs refers to physiologic changes BEFORE/PRECEDING labor (e.g., back pain, weight loss, contractions, lightening, etc)

Physiologic changes preceding labor (premonitory signs)

1. Low Backache (constant, dull)

• Caused by pelvic muscle relaxation.

2. Weight Loss (0.5 to 1.5 kg (1 to 3.5 lbs))

• Hormonal changes lead to fluid shifts and loss of water

3. Lightening (Baby Drops)

• The fetal head descends into the pelvis (usually about 14 days before labor in first-time pregnancies).

• Symptoms: Easier breathing, but increased pressure on the bladder, causing frequent urination.

• Note: More noticeable in first pregnancies (primigravida).

4. Irregular Uterine Contractions (Braxton Hicks)

• These "practice" contractions gradually become stronger, more frequent, and regular.

5. Increased Vaginal Discharge/Bloody Show

• Expulsion of the cervical mucus plug.

• Appearance of brownish or blood-tinged mucus, signaling the start of cervical dilation and effacement.

6. Energy Burst ("Nesting Instinct")

• A sudden surge of energy, often leading to preparing the home for the baby.

7. Gastrointestinal Changes (n/v, indigestion)

8. Cervical Ripening

• The cervix softens (ripens), begins to open (dilate), and becomes thinner (effaces) in preparation for labor.

9. Rupture of Membranes (Water Breaks)

• The amniotic sac may rupture spontaneously, either initiating or occurring during labor.

• Labor typically starts within 24 hours after the rupture.

  • If membranes remain ruptured for more than 24 hours, the risk of infection increases.

  • Nursing Alert: Immediately check Fetal Heart Rate (FHR) to monitor for signs of umbilical cord prolapse or fetal distress.

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Utilize the premonitory and physiological signs of labor to differentiate between true and false labor.

Rupture of Membranes / ROM (Water Breaks)

When the amniotic sac (keeping the baby afloat) ruptures (can occur before or during labor)

Typically starts within 24 hours of labor

• Infection risk increases if any longer

Initiates natural hormone secretion (oxytocin) to facilitate contractions

• Some mothers want to avoid medications during this time for a more natural birth

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Assess fetal heart rate (FHR) for fetal distress IMMEDIATELY

• If too low, cord could be occluded

Assess cervix for umbilical cord prolapse

• Medical Emergency: If cord felt, keep hand inside to create space for the cord

Record time, color, and odor of fluid.

Perform Nitrazine or Ferning tests to confirm​.

What happens when ROM happens?

Hormones secrete to facilitate contractions

• Oxytocin

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Some mothers want to avoid medications during this time for a more natural birth

What immediate actions must be done when the water breaks (Post-ROM)?

Assess fetal heart rate (FHR) for fetal distress

• AND 5 minutes later

• If too low, cord could be affected

Record time, color, and odor of fluid.

Assess cervix for umbilical cord prolapse but limit vaginal examinations

• Medical Emergency: If cord felt, keep hand inside to create space for the cord

Assess temperature Q1-2 HR / per policy

Perform Nitrazine (pH) or Ferning (microscope slide) tests to confirm​.

Notify HCP if meconium present

Cervical Ripening

Cervix softens, preparing or beginning to open (dilate) and thin (efface) in preparation for labor

Lightening

Premonitory Sign

When the “baby drops”

• The fetal head descends into the pelvis (usually about 14 days before labor in first-time pregnancies).

• Symptoms: Easier breathing, but increased pressure on the bladder, causing frequent urination.

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More noticeable in first pregnancies (primigravida)

Braxton Hicks

Premonitory Sign

“Irregular, practice contractions”

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Become more stronger, regular, frequent

Decreases with hydration and walking

Braxton Hicks vs True Contractions (No Table)

Decreases with hydration and walking

Irregular frequency, duration, intensity

No bloody show

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DOES NOT decrease with hydration or walking

Regular frequency, duration, intensity

Stronger when walking

LEADS TO CERVICAL DILATION/EFFACEMENT

Cervical mucus plug

Thick, gelatinous substance that fills and seals the cervical canal during pregnancy

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Expelled as a Premonitory Sign aka “Bloody Show”

What sign may indicate the start of cervical dilation/effacement

Appearance of brownish or blood-tinged mucus

• Indicates expulsion of the cervical mucus plug.

  • Premonitory Sign

Nesting Instinct

Premonitory Sign

aka Energy Burst

• A sudden surge of energy, often leading to preparing the home for the baby.

Preterm

20-36-6/7 weeks gestation

Term

=>37 weeks gestation

Abortion

<20 weeks gestation

Fetal/Abrupt Decelerations

Short-term but clear decreases of the fetal heart rate (FHR) identified during fetal heart monitoring.

Hydramnios

Condition where there is an excessive amount of amniotic fluid surrounding the developing fetus in the uterus

>25 cm surrounds

Oligohydramnios

Condition where there is too little an amount of amniotic fluid surrounding the developing fetus in the uterus

<5 cm surrounds

FIVE P’s: Passenger (Fetus and Placental Navigation)

Key Factors:

1. Presentation: The part of the fetus entering the pelvic inlet first.

   • Examples: Back of the head (occiput), shoulder, breech (sacrum/feet), or face.

2. Lie: Relationship of the maternal spine to the fetal spine.

   • Transverse: Fetal spine is horizontal (requires a C-section).

   • Parallel/Longitudinal: Fetal spine aligns with maternal spine (cephalic or breech presentation).

3. Attitude: Relationship of fetal body parts to each other.

   • Flexion: Chin tucked, extremities flexed toward body (ideal for delivery).

   • Extension: Chin extended away, less favorable.

4. Fetopelvic (Fetal) Position: The position of the presenting part in relation to the mother’s pelvis.

   • Three Letters:

     • First letter: Right (R) or Left (L) side of the maternal pelvis.

     • Second letter: Presenting part (Occiput [O], Sacrum [S], Mentum [M], or Scapula [Sc]).

     • Third letter: Position (Anterior [A], Posterior [P], or Transverse [T]).

5. Station: Measurement of fetal descent into the pelvis.

   • 0 station: Fetal head is at the level of the ischial spines.

   • Negative station: Above the spines.

   • Positive station: Below the spines.

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Molding Helps the Fetus Exit

Differentiate between fetal lie, fetal presentation, fetal positions, & fetal attitude.

Passenger: Fetal Presentations/Positions

Vertex / Cephalic

LOA / ROA

• Occiput facing left/right quadrant and anterior (symphysis pubis): ideal (can tuck chin)

LOT / ROT

• Occiput facing left/right quadrant and anterior (symphysis pubis) / posterior (sacrum)

LOP / ROP

• Occiput facing left/right quadrant and posterior (sacrum): not ideal (applies pressure to sacrum, cannot tuck chin)

97% of all term births

Face

LMA / RMA

• Mentum facing left/right quadrant and anterior (symphysis pubis)

LMP/RMP

• Mentum facing left/right quadrant and posterior (sacrum)

Breech

LSA/RSA

• Sacrum facing left/right quadrant and anterior (symphysis pubis)

LSP/RSP

• Sacrum facing left/right quadrant and posterior (sacrum)

Subdivided: Complete (butt first, legs crossed), Frank (butt first, body doubled), Footling (foot/feet first)

Transverse

• Acromion first

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Charted using the three-letter notation:

• First Letter: Maternal side (R = Right, L = Left).

• Second Letter: Presenting part (O = Occiput, S = Sacrum, A= Acromion, M = mental/face, B= Brow).

• Third Letter: Orientation (A = Anterior, P = Posterior, T = Transverse).

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"WHICH PART OF THE FETUS REACHES THE PELVIC INLET (HOLE) FIRST?”

Anterior Positions (ROA & LOA)

Facilitate smoother labor progression as the fetal head is aligned with the pelvic outlet.

Posterior Positions (ROP & LOP)

May require additional interventions, such as manual rotation or assisted delivery (e.g., forceps or vacuum).

• Applies pressure to sacrum (posterior quadrant)

• Baby cannot properly tuck chin

Passenger: Fetal Vertex Presentations (Image)

LOA / ROA

• Occiput facing left/right quadrant and anterior (symphysis pubis): ideal

LOT / ROT

• Occiput facing left/right quadrant and anterior (symphysis pubis) / posterior (sacrum)

LOP / ROP

• Occiput facing left/right quadrant and posterior (sacrum): not ideal

Passenger: Fetal Face Presentations (Image)

LMA / RMA

• Mentum facing left/right quadrant and anterior (symphysis pubis)

LMP/RMP

• Mentum facing left/right quadrant and posterior (sacrum)

Passenger: Fetal Breech Presentations (Image)

LSA/RSA

• Sacrum facing left/right quadrant and anterior (symphysis pubis)

LSP/RSP

• Sacrum facing left/right quadrant and posterior (sacrum)

Passenger: Attitude (Image)

Relationship of fetal body parts to each other.

• Flexion: Chin tucked, extremities flexed toward its trunk/body (ideal for delivery).

• Extension: Chin extended away, less favorable.

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“HOW TIGHT IS THE FETUS?”

Passenger: Lie

Relationship of the maternal longitudinal axis/spine to the fetal spine.

• Transverse: Fetal spine is horizontal (requires a C-section).

• Parallel/Longitudinal: Fetal spine aligns with maternal spine (cephalic or breech presentation).

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“WHICH AXIS IS THE FETUS RELATIVE TO MOTHER’S SPINE?”

Passenger: Station

Relationship of presenting part vs maternal pelvic ischial spines

Measurement of fetal descent into the pelvis.

• 0 station: Fetal head is at the level of the ischial spines.

• Negative station “-”: Above the spines.

  • -1 to -5 (at the inlet)

• Positive station “+”: Below the spines.

  • +1 to +4 (at the outlet or crowning)

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DO NOT AROM if NEGATIVE

• Risks cord prolapse/tangling

“HOW DEEP IS THE FETUS?”

Five P’s (Factors That Affect/Define Labor & Delivery Process)

Passenger (Fetus + Placenta)

• 5 subtypes

  • Presentation, lie, attitude, fetopelvic positions, station

Passageway (Birth Canal)

• 4 Subtypes

  • Gynecoid: Favorable for vaginal delivery.

    Android, Anthropoid, Platypelloid: Less favorable​

Powers (Contractions)

• 2 Subtypes

  • Primary - involuntary

  • Secondary - Voluntary

Position (of mother)

Psychological response (Emotions of mother)

Mentum

face

Occiput

back of head

Cephalic lie

Upside down fetus (expected finding)

Breech lie

Right-side up fetus (unexpected finding)

Mecnoium

First poop

SROM

Spontaneous Rupture of Membranes

AROM (Artificial Rupture of Membranes)

Purpose

• Helps stimulate labor

• If no ROM after full dilation

• If internal monitoring necessary

Procedure is called called amniotomy

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DO NOT PERFORM UNLESS BABY IS ENGAGED (NOT A MINUS/NEGATIVE STATION)

FIVE P’s: Passageway (Birth Canal)

Components: Bony pelvis, cervix, pelvic floor, vagina, and vaginal opening.

Key Points:

• Size and shape of the bony pelvis are crucial.

  • Gynecoid: Favorable for vaginal delivery.

    Android, Anthropoid, Platypelloid: Less favorable​

• Cervix must dilate (open 10cm) and efface (thin) for the fetus to descend.

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The fetus must pass through this bony canal during the vaginal birth process. It is divided into 3 sections:

• The inlet (top portion)

• The pelvis cavity (hole)

• The outlet (bottom portion)

FIVE P’s: Powers (Contractions)

Primary:

• Uterine contractions cause:

  • Effacement (thinning of the cervix).

  • Dilation (widening of the cervix).

Secondary: Voluntary bearing down and pushing by the mother.

FIVE P’s: Position (Maternal)

Benefits:

• Reduces fatigue and improves comfort.

• Promotes fetal descent using gravity.

• Positions include upright, kneeling, and squatting.

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Encourage frequent position changes during labor

• Upright uses gravity

• Hands/knees relieves back pressure

• Ball helps rotate baby

No supine – compression of vessels

FIVE P’s: Psychological Response (Maternal)

Impact: Maternal stress, tension, and anxiety can:

• Slow labor progress.

• Increase pain perception.

• Affect uterine contractions negatively.

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Provide emotional support to reduce fear and promote relaxation.

• Orient To The Room, Call Her By Name, Encourage Verbalization, Listen Attentively, Answer All Questions- Re-answer Prn, Explain Procedures, Give Choices When Possible, Keep Informed Of Progress, Encourage Relaxation Techniques, Encourage Support Person To Participate, Provide Reassurance And Praise, Remain Calm And In Control During Emergencies, Explain That No Two Labors Are Alike, Don’t Make Promises, If Lips Are Tingling Or Lightheaded (Hyperventilating) Give Paper Bag Or Have Patient Breath Into Cupped Hands

Fetal Heart Rate w/ Uterine Pattern (Image)

Preprocedure Nursing Actions

1. Leopold Maneuvers:

   • Abdominal palpation to determine:

     • Fetal presenting part (e.g., head, breech).

     • Lie (longitudinal or transverse).

     • Attitude (flexion or extension).

     • Descent in the pelvis.

   • Helps locate the best area to listen to fetal heart tones (FHT).

2. External Electronic Monitoring (Tocotransducer):

   • A device placed on the maternal abdomen to measure:

     • Uterine contraction patterns.

   • Key Points:

     • Easy to apply.

     • Must be repositioned if the mother moves.

3. External Fetal Monitoring (EFM):

   • A transducer placed on the abdomen to monitor fetal heart rate (FHR) during labor and birth.

   • Tracks patterns to assess fetal well-being.

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Updates about the labor and delivery process.

Opportunity for the client to ask questions or clarify procedures.

Provides reassurance and preparation for the next steps.

Preprocedure Labs

1. Group B Streptococcus (GBS):

   • A culture taken if not already done at 36-37 weeks of gestation.

   • Positive Result: Requires IV prophylactic antibiotics to prevent transmission to the baby.

2. Urinalysis (Clean-catch sample):

   • Assesses for:

     • Dehydration: Measured via specific gravity.

     • Ketones: Signs of poor nutrition or uncontrolled glucose.

     • Proteinuria: Indicates gestational hypertension or preeclampsia.

     • Glucosuria: Suggests gestational diabetes.

     • Urinary Tract Infection (UTI): Identified via bacterial count.

   • Includes universal drug screening for maternal safety.

3. Blood Tests:

   • CBC: Checks for anemia, infection, and clotting abnormalities.

   • ABO Typing and Rh Factor: Ensures compatibility to prevent hemolytic disease in the newborn.

   • No Prenatal Care: All necessary bloodwork is drawn if prenatal testing was missed.

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Updates about the labor and delivery process.

Opportunity for the client to ask questions or clarify procedures.

Provides reassurance and preparation for the next steps.

Leopold Maneuvers

Abdominal palpation to determine:

• Fetal presenting part (e.g., head, breech).

• Lie (longitudinal or transverse).

• Attitude (flexion or extension).

• Descent in the pelvis.

Helps locate the best area to listen to fetal heart tones (FHT).

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Do before labor

External Electronic Monitoring (Tocotransducer) / TOCO

A device placed on the maternal abdomen to measure:

• Uterine contraction patterns

Easy to apply.

Must be repositioned if the mother moves.

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Do before labor

External Fetal Monitoring (EFM)

A transducer placed on the abdomen to monitor fetal heart rate (FHR) during labor and birth.

Tracks patterns to assess fetal well-being.

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Do before labor.

Pelvic inlet

The “hole” above the pelvic cavity

Marks the boundary between the greater pelvis and lesser pelvis.

Its size is defined by its edge, the pelvic brim.

Determines the size and shape of birth canal

Borders

• Posterior – sacral promontory (the superior portion of the sacrum) and sacral wings (ala).

• Lateral – arcuate line on the inner surface of the ilium, and the pectineal line on the superior pubic ramus.

• Anterior – pubic symphysis.

Pelvis Anatomy (Video)

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Intraprocedure Nursing Actions

1. Assess Maternal Vital Signs

• Check temperature every 2 hours if membranes are ruptured

2. Assess Fetal Heart Rate (FHR)

• Tools:

  • External Fetal Monitor (EFM): Applied to the abdomen.

  • Spiral Electrode: Applied to the fetal scalp (requires ruptured membranes and cervical dilation).

3. Assess Uterine Contraction Characteristics

• Method: Palpation of the uterine fundus or use of external/internal monitors.

• Key Terms:

  • Frequency: Time from the start of one contraction to the start of the next.

  • Duration: Time from the beginning to the end of one contraction.

  • Intensity: Strength of contraction at its peak:

    • Mild (feels like pressing the tip of the nose).

    • Moderate (feels like pressing the chin).

    • Strong (feels like pressing the forehead).

  • Resting Tone: Uterine muscle tone between contractions (important for fetal oxygenation).

    • Prolonged contraction duration or frequent contractions (>5 in 10 minutes) can lead to fetal hypoxia and abnormal FHR patterns.

4. Intrauterine Pressure Catheter (IUPC)

• A sterile catheter is inserted to measure the pressure of uterine contractions.

• Requirements: Ruptured membranes and sufficient cervical dilation.

• Use: Provides more precise contraction data.

5. Vaginal Examination

• Performed digitally by a qualified nurse or provider to assess:

  1. Cervical Dilation and Effacement:

     • Dilation: Opening of the cervix (measured in cm).

     • Effacement: Thinning and shortening of the cervix (measured in percentage).

  2. Fetal Descent: Station (distance of fetal presenting part in relation to ischial spines).

  3. Fetal Position and Presentation: Part of the fetus leading through the pelvis.

  4. Membrane Status: Intact or ruptured.

How many contractions within a short time risks fetal hypoxia and abnormal FHR patterns?

MORE THAN 5 in 10 MINUTES

• “>5 UC Q10min” (Tachysystole)

Measures Fetal Heart Rate

External Fetal Monitor (EFM): Applied to the abdomen.

Spiral Electrode: Applied to the fetal scalp (requires ruptured membranes and cervical dilation).

Intrauterine pressure catheter (IUPC)

A sterile catheter inserted to measure the pressure of uterine contractions.

Requirements: Ruptured membranes and sufficient cervical dilation.

Use: Provides more precise contraction data.

Measures Uterine Contractions

Tocotransducer (external)

Intrauterine pressure catheter (more precise)

Spiral Electrode

Another way to check fetal heart rate

Applied to the fetal scalp (requires ruptured membranes and cervical dilation) during labor

Intraprocedure Examination (Vaginal)

Performed digitally by a qualified nurse or provider to assess:

1. Cervical Dilation and Effacement:

   • Dilation: Opening of the cervix (measured in cm).

   • Effacement: Thinning and shortening of the cervix (measured in percentage).

2. Fetal Descent: Station (distance of fetal presenting part in relation to ischial spines).

3. Fetal Position and Presentation: Part of the fetus leading through the pelvis.

4. Membrane Status: Intact or ruptured.

Uterine Contraction Characteristics

Frequency: Time from the start of one contraction to the start of the next.

Duration: Time from the beginning to the end of one contraction.

Intensity: Strength of contraction at its peak:

• Mild (feels like pressing the tip of the nose).

• Moderate (feels like pressing the chin).

• Strong (feels like pressing the forehead).

Resting Tone: Uterine muscle tone between contractions (important for fetal oxygenation).

• Prolonged contraction duration or frequent contractions (>5 in 10 minutes) can lead to fetal hypoxia and abnormal FHR patterns.

CARDINAL MOVEMENTS: Mechanisms of Labor (Vertex Presentation)

1. Engagement:

   • Fetal head passes through the pelvic inlet at station 0 (ischial spines level)

2. Descent:

   • Movement of the fetus down the birth canal (measured as negative or positive station).

3. Flexion:

   • Fetal head flexes (chin to chest) to fit through the pelvis.

4. Internal Rotation:

   • Fetal occiput rotates to a lateral position as it moves through the pelvis.

5. Extension:

   • Fetal head emerges under the pubic symphysis and extends to deliver.

6. External Rotation (Restitution):

   • After the head is born, it rotates back to align with the shoulders.

7. Birth by Expulsion:

   • After rotation, the baby is delivered completely as the shoulders and trunk pass through the birth canal.

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EVERY DAY FAT INFANTS EAT EXTRA BREASTMILK

https://www.youtube.com/embed/EQUVbmLXQSI

EVERY DAY FAT INFANTS EAT EXTRA BREASTMILK (CARDINAL MOVEMENTS)

Mechanisms of Labor (Vertex Presentation)

• Engage (head reaches station 0)

• Descent

• Flexion (chin tuck to fit)

• Internal Rotation (occiput rotates toward lateral)

• Extension (chin untuck past pubic symphysis)

• External Rotation aka Restitution (head pops out, then re-aligns w/ trunk)

• Birth by Expulsion (shoulders and trunk pass)

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https://www.youtube.com/embed/EQUVbmLXQSI

Restitution

To restore or return to

References 6th of 7 Mechanisms of Labor (External Rotation to realign w/ shoulders

Postprocedure Nursing Actions & Education

1. Maternal Vital Signs

   • BP/Pulse: Q15 × 8 (first 2 hours)

   • Temp: Q4H x 2 (first 8 hours), then Q8H

2. Fundus:

   • Assess firmness and position to prevent uterine atony (soft uterus).

     • Q15 × 4 (first hour), then follow protocol

   • Massage PRN to maintain firmness

   • Administer oxytocics (e.g., ptocin) as prescribed to prevent hemorrhage

3. Lochia:

   • Monitor type, color, and amount of vaginal discharge.

     • Q15 × 4 (first hour), then follow protocol

4. Perineum:

   • Check for swelling, lacerations, or signs of infection.

   • Provide comfort measures (e.g., ice packs, analgesia)

5. Urinary Output:

   • Ensure the bladder is not distended, as this can interfere with uterine contractions.

     • Encourage voiding

6. Maternal/Newborn Bonding:

   • Encourage activities such as skin-to-skin contact and breastfeeding.

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Educate to notify if:

• Increased vaginal bleeding.

• Passage of large blood clots.

• Signs of infection (fever, unusual discharge, or foul odor).

True vs. False (e.g., Braxton Hicks) Contractions (Table)

Leads to cervical dilation and effacement, with stronger, regular contractions that persist.

“Bloody show” (vaginal bleeding) evident

Stronger when walking

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No cervical changes, and contractions are irregular, painless, and stop with comfort measures.

Contractions felt in low back

Decreases with hydration and walking

True Labor

Contractions:

• Begin irregularly but become regular in frequency.

• Stronger, last longer, and occur more frequently over time.

• Felt in the lower back and radiate to the abdomen.

• Walking increases contraction intensity.

• Do not stop with comfort measures (e.g., rest, hydration).

Cervix (Assessed by Vaginal Exam):

• Progressive changes in dilation (opening) and effacement (thinning).

• Moves to an anterior position (closer to the front).

• Presence of a bloody show.

Fetus:

• Presenting part engages in the pelvis (descends into position for delivery).

False Labor

Contractions:

• Painless, irregular, and intermittent.

• Decrease in frequency, duration, and intensity with walking or position changes.

• Felt in the lower back or abdomen above the umbilicus.

• Often stop with sleep or comfort measures (e.g., hydration, emptying the bladder).

Cervix (Assessed by Vaginal Exam):

• No significant change in dilation or effacement.

• Cervix often remains in a posterior position (closer to the back).

• No significant bloody show.

Fetus:

• Presenting part is not engaged in the pelvis.

NSVD

Normal spontaneous vaginal delivery

VBAC

Vaginal birth of a C/S (c-section)

BOW

Bag of water

EFM

Electronic fetal monitoring

FHT/FHR

Fetal heart tone or fetal heart rate

PRIMIP

Woman delivering a baby for the first time

Nagel’s Rule

LMP Date: -3 Months +7 days (Knuckles: Months w/ 31 days)

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6/11 = 3/18

4/18 = 1/25

3/11: 12/18

5/25: 3/4

6/30: 4/7

EDD/EDC

Estimated date of confinement or delivery

LMP

Last Menstrual Period

PPROM

Preterm Premature Rupture of Membrane

• Before UCs start (high risk of infection, cord compression, cord prolapse)

• Before 37 weeks gestation

PROM

Premature Rupture of Membrane

• Before UCs start (high risk of infection, cord compression, cord prolapse)

Multip

Woman delivered a baby before

GRAN Multip

Woman delivered 5+ babies before

What is the definitive sign of true labor (not false labor)?

Cervix thins and dilates

GTPAL (Pregnancy Assessment)

Gravidity (number of pregnancies)

• Present pregnancy

• Miscarriages/abortion

• Twin/triplets count as one

Term births (delivered >37 weeks)

• Alive or stillborn

• Twins/triplets count as one

Pre-term births (delivered 20-36-6/7 weeks)

• Alive or stillborn

• Twins/triplets count as one

Abortions/Miscarriages (delivered <20 weeks)

• Counts toward gravidity

• Twins/triplets count as one

Living children

• Twin/triplets count individually

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Always count the current pregnancy

NULLGRAVIDA

Never been pregnant

How do you help rotate an OP baby?

Maternal positions

• Have the mother perform upright positions/exercises

  • Opens her pelvis

  • Aids effacement

  • Helps perception of pain

• NEVER SUPINE (compresses the vessels)

Which passageways are ideal and not ideal for vagina delivery?

Gynecoid: Favorable for vaginal delivery.

Android, Anthropoid, Platypelloid: Less favorable​

Nursing Responsibilities (Assessment)

Assess Labor Status (Pre-Admission):

• Take admission history

• Review the birth plan.

• Obtain laboratory reports for any abnormalities.

• Monitor baseline FHTs and UC patterns for 20–30 minutes.

• Check maternal vital signs for distress or complications.

• Assess amniotic membranes state (e.g., ruptured or intact).

Orientation:

• Orient the client and their partner to the unit upon admission.

Continuous Maternal and Fetal Monitoring (Admission):

• Perform continuous assessments of both the mother and fetus throughout labor and immediately after birth.

• Avoid vaginal examinations if:

  • There is vaginal bleeding.

  • Placenta previa or abruptio placentae is suspected (these conditions should only be handled by the provider).

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Key Indicators of Labor Progress

• Cervical Dilation:

  • Most reliable indicator of labor progress (measured in cm).

• Factors Affecting Labor Progress:

  • Size of the fetal head.

  • Fetal presentation (e.g., head-first or breech).

  • Fetal lie (alignment of the fetus with the maternal spine).

  • Fetal attitude (flexion or extension).

  • Fetal position in the pelvis.

• Contraction Characteristics:

  • Frequency, duration, and strength of contractions are critical for:

    • Fetal descent (lightening)

    • Cervical dilation.

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Explain the needed information during the admission process to labor and delivery.

Key Indicators of Labor Progress

Cervical Dilation:

• Most reliable indicator of labor progress (measured in cm).

Factors Affecting Labor Progress:

• Size of the fetal head.

• Fetal presentation (e.g., head-first or breech).

• Fetal lie (alignment of the fetus with the maternal spine).

• Fetal attitude (flexion or extension).

• Fetal position in the pelvis.

Contraction Characteristics:

• Frequency, duration, and strength of contractions are critical for:

  • Fetal descent (lightening)

  • Cervical dilation.