LABOR & DELIVERYLABOR & DELIVERY Lecture 6Lecture 6

IntroductionIntroduction

Uterus: pear-shaped muscle made of 3 Uterus: pear-shaped muscle made of 3 layers: layers:

Endometrium – inner lining - shed during Endometrium – inner lining - shed during menses.menses.

Myometrium - muscle layer – middle Myometrium - muscle layer – middle Perimetrium - outer layer -extra support to Perimetrium - outer layer -extra support to

whole structure.whole structure.

THEORIES of LABOR:THEORIES of LABOR: Combination of factors startCombination of factors start labor: labor: Oxytocin & prostaglandin - most important Oxytocin & prostaglandin - most important

biochemical factors in stimulating uterine biochemical factors in stimulating uterine contractions. contractions.

Estrogen ↑ uterus response & progesterone Estrogen ↑ uterus response & progesterone ↓ it.↓ it.

THEORIES:THEORIES:

Oxytocin Stimulation: Term uterus Oxytocin Stimulation: Term uterus sensitive to oxytocin ↑ d/t pressure sensitive to oxytocin ↑ d/t pressure exerted on cervix by fetus.exerted on cervix by fetus.

Progesterone Withdrawl: ↓ progesterone Progesterone Withdrawl: ↓ progesterone by fetus & ↑ prostaglandins in by fetus & ↑ prostaglandins in chorioamnion results in ↑ uterine contxs. chorioamnion results in ↑ uterine contxs.

Estrogen Stimulation: ↓ progesterone Estrogen Stimulation: ↓ progesterone allows estrogen to ↑ contractile response allows estrogen to ↑ contractile response of uterus. of uterus.

Fetal Cortisol: Changes biochemistry of Fetal Cortisol: Changes biochemistry of fetal membrane: ↓ progesterone & ↑ fetal membrane: ↓ progesterone & ↑ prostaglandin in placenta.prostaglandin in placenta.

Distention: uterine muscles stretch causing Distention: uterine muscles stretch causing ↑ prostaglandin.↑ prostaglandin.

Amniotic membranes (sac) makes Amniotic membranes (sac) makes arachidonic Acid → Prostaglandin - ^ arachidonic Acid → Prostaglandin - ^ uterine contractility. uterine contractility.

Premonitory signs of labor: weeks before real Premonitory signs of labor: weeks before real labor labor

AKA AKA ““False LaborFalse Labor””

Lightening: Fetus settles into pelvic cavity. Lightening: Fetus settles into pelvic cavity. Braxton-Hicks: Irregular intermittent contractions; Braxton-Hicks: Irregular intermittent contractions;

““false laborfalse labor””; DO NOT initiate true labor.; DO NOT initiate true labor. Cervical changes: cervix effaces [thins] & dilates Cervical changes: cervix effaces [thins] & dilates

slightly slightly Baby's head in pelvis pushes against cervix Baby's head in pelvis pushes against cervix

causing relaxation and effacement.causing relaxation and effacement. Burst of Energy: Nesting instinct; cleans house, Burst of Energy: Nesting instinct; cleans house,

sets up nursery. ↑ epinephrine resulting from ↓ sets up nursery. ↑ epinephrine resulting from ↓ progesteroneprogesterone

Cervix in posterior position.Cervix in posterior position.

Signs True Labor: closer to time of deliverySigns True Labor: closer to time of delivery

Uterine Contractions: regular & frequent Uterine Contractions: regular & frequent compared to Braxton-Hicks. Stronger w. time.compared to Braxton-Hicks. Stronger w. time.

Bloody Show: pink tinged secretions d/t softening Bloody Show: pink tinged secretions d/t softening cervix.(aka mucous plug)cervix.(aka mucous plug)

Rupture of Membranes: (ROMRupture of Membranes: (ROM) Labor in 24 ) Labor in 24 hrs. Multiparas sooner. Big gush or slow trickle. hrs. Multiparas sooner. Big gush or slow trickle.

Clear/odorless. Clear/odorless. Green/brown, Green/brown, danger signdanger sign MMeconium econium aspiration > distress/infection.aspiration > distress/infection. Immediate medical attention. Immediate medical attention.

PROM or prolonged ROM –PROM or prolonged ROM – intrauterine infection intrauterine infection [pathogens reach fetus] [pathogens reach fetus]

Difference Between True & False Labor:Difference Between True & False Labor:

True LaborTrue LaborA. regular contxA. regular contx’’s s B. discomfort begins in back & spreads to abdomen. B. discomfort begins in back & spreads to abdomen. C. progressive cervical dilation/effacementC. progressive cervical dilation/effacementD. Interval between contx.D. Interval between contx.’’s become shorters become shorterE. intensity of contx.E. intensity of contx.’’s ↑ with ambulation s ↑ with ambulation F. contx.F. contx.’’s ↑ in duration & intensitys ↑ in duration & intensity

False Labor False Labor A. irregular contx.A. irregular contx.’’ssB. discomfort localized in abdomen B. discomfort localized in abdomen C. no changeC. no changeD. No changeD. No changeE. Ambulation has no effectE. Ambulation has no effectF. No changeF. No change

““STAGES of LABORSTAGES of LABOR”” 4 in All !4 in All !

First StageFirst Stage

Onset of true labor to complete dilation = 10 cm. Onset of true labor to complete dilation = 10 cm. ~ 6-18 hrs. primapara; 2-10 hrs. multipara. ~ 6-18 hrs. primapara; 2-10 hrs. multipara. Cervix becomes more anterior.Cervix becomes more anterior.

3 phases3 phases: Latent, Active, Transitional. : Latent, Active, Transitional. LatentLatent:: Dilation 0-3 cms. Contx. Dilation 0-3 cms. Contx.’’s mild/irregular.s mild/irregular.ActiveActive:: 4-7 cms. Contx. 4-7 cms. Contx.’’s 5-8 min. apart. s 5-8 min. apart. Lasts 45-60 sec; moderate - strong intensity.Lasts 45-60 sec; moderate - strong intensity.Transitional:Transitional: Dilation 8-10 cms. Contx. Dilation 8-10 cms. Contx.’’s 1-2 s 1-2 min. apart; 60 min. apart; 60 ––90 sec.; strong intensity.90 sec.; strong intensity. No pushing til fully dilated. No pushing til fully dilated.

Second StageSecond Stage: “Birthing of : “Birthing of Baby”Baby”

Delivery of infant: Delivery of infant:

up to 1 hr. or ~ 20 contxup to 1 hr. or ~ 20 contx’’s – primip. s – primip. 20 min. or ~ 10 contx20 min. or ~ 10 contx’’s in multip. s in multip. Can last up to 3 hrs.!Can last up to 3 hrs.!

Cardinal movements occur here. Cardinal movements occur here.

Most difficult & uncomfortable part of labor.Most difficult & uncomfortable part of labor.

Crowning occurs at +4 -+5 station.Crowning occurs at +4 -+5 station.

Strong urge to push & bear down as infant passes Strong urge to push & bear down as infant passes through vagina & rectum – may have BM.through vagina & rectum – may have BM.

Positions: Sitting, Side Lying, Standing, Squatting, All Positions: Sitting, Side Lying, Standing, Squatting, All Fours, Kneeling.Fours, Kneeling.

“Crowning” - External view “Cardinal Movements” - Internal

motions

Third StageThird Stage

Delivery of Delivery of placentaplacenta ~ 5 - 30 min. ~ 5 - 30 min.Separation should be automatic [uterus contracts & Separation should be automatic [uterus contracts &

mom bears down]mom bears down]Don’t palpate non-contracted uterus –possible Don’t palpate non-contracted uterus –possible

eversion. Maternal vessels still open. eversion. Maternal vessels still open.

MD/MW presses on MD/MW presses on contractedcontracted uterus. “ uterus. “ CCrederede’s ’s Maneuver”Maneuver”

Pitocin > placenta delivered to avoid retained Pitocin > placenta delivered to avoid retained placenta. placenta.

If no spontaneous delivery of placenta, manually If no spontaneous delivery of placenta, manually removed.removed.

AntibioticsAntibiotics

Fourth StageFourth Stage

Placenta out; mother recovers in Placenta out; mother recovers in “LDR” “LDR”

“ “Labor, delivery, & recovery”Labor, delivery, & recovery”

Lasts ~ 1 hr. unless complications Lasts ~ 1 hr. unless complications arise. arise.

Then pt. transferred to PP unit.Then pt. transferred to PP unit.

Nursing Interventions During Nursing Interventions During LaborLabor

Triage - Admit clientTriage - Admit client to birthing area to birthing area

[MD determines true labor][MD determines true labor] Emotional support & encourage rest Emotional support & encourage rest Progress of labor Progress of labor Monitor/document contractions & FHR q 15 Monitor/document contractions & FHR q 15

min.min. MMonitor/document maternal VS q 1 - 4 onitor/document maternal VS q 1 - 4

hrhr Assess pain & provide pain relief as Assess pain & provide pain relief as

prescribed prescribed

.

Nursing Interventions ContNursing Interventions Cont..

* Provide comfort measures [back rub, ice chips]* Provide comfort measures [back rub, ice chips]* Explain equipment & procedures.* Explain equipment & procedures.* * Observe & document time of ROMObserve & document time of ROM Supine hypotension – Position on side - Supine hypotension – Position on side -

pressure off vena cavapressure off vena cava Role of coach during active/transitional Role of coach during active/transitional

stages stages Assist with pushing during 2Assist with pushing during 2ndnd stage. stage. Record time of delivery, Apgar score, Record time of delivery, Apgar score,

spontaneous cry, & resuscitative efforts to spontaneous cry, & resuscitative efforts to infantinfant

Monitor infant for extrauterine life Monitor infant for extrauterine life adjustmentadjustment

Encourage family bonding > deliveryEncourage family bonding > delivery

Breathing Techniques Breathing Techniques

Slow chest:Slow chest: 6-12 “easy” breaths/min. Used in 6-12 “easy” breaths/min. Used in early labor. early labor.

Combination:Combination: quicker, lighter breaths quicker, lighter breaths Used during active labor; one slow breath in Used during active labor; one slow breath in

beginning & quicker breaths to follow.beginning & quicker breaths to follow. Pant-Blow:Pant-Blow: 3 - 4 quick breaths, with forceful 3 - 4 quick breaths, with forceful

exhalation. Used @ exhalation. Used @ endend of 1st stage when of 1st stage when contx.’s strongest.contx.’s strongest.

EliminationElimination Monitor UO q 2-4 hr. Monitor UO q 2-4 hr. Pressure of fetal head reduces bladder Pressure of fetal head reduces bladder

tone. tone. Full bladder > inhibits labor. Full bladder > inhibits labor. Catheterize. Remove > delivery.Catheterize. Remove > delivery.

HydrationHydration IV to hydrate; pt. diaphoretic & NPO x ice IV to hydrate; pt. diaphoretic & NPO x ice

chips.chips. Lactated ringers; good volume expander.Lactated ringers; good volume expander.

Assessing Progress of Labor Assessing Progress of Labor Dilation: 0Dilation: 0––10 cm. [opening cervix]10 cm. [opening cervix] Effacement: 0 Effacement: 0 ––100 % [thinning cervix]100 % [thinning cervix] Station: Relationship of presenting part to Station: Relationship of presenting part to

pelvic pelvic ischial spinesischial spines - -midwaymidway in pelvic cavity. in pelvic cavity. ““0 0 ”” station aka station aka ““eengagedngaged””.. -1 to -5 -1 to -5 aboveabove “0” “0” +1 to +5 (outlet) +1 to +5 (outlet) belowbelow “0” “0” +4/+5: baby's head out. +4/+5: baby's head out.

Mechanism of LaborMechanism of Labor: : passage of fetus thru birth passage of fetus thru birth canal involves position changescanal involves position changes called: called: Cardinal Cardinal

Movements of Labor:Movements of Labor: mechanical & spontaneous. mechanical & spontaneous. “2“2ndnd stage”stage”

EngagementEngagement: presenting part enters : presenting part enters midpointmidpoint of of pelvis @ ischial spines. pelvis @ ischial spines.

DescentDescent:: downward movement thru pelvic inlet, downward movement thru pelvic inlet, thru dilated cervix, reaches posterior vaginal thru dilated cervix, reaches posterior vaginal floor. Mom feels like pushing. Widest part [head] floor. Mom feels like pushing. Widest part [head]

passed passed thru pelvis. thru pelvis. “active forces of labor.”“active forces of labor.”

FlexionFlexion:: pressure from pelvic floor causes head to pressure from pelvic floor causes head to flex towards chest; chin touches chest.flex towards chest; chin touches chest.

Internal RotationInternal Rotation: occiput [back of head] : occiput [back of head] in in

diagonal position & rotates towards diagonal position & rotates towards face face down down

position. / to ↓ position. / to ↓ (occurs as body parts press on bony (occurs as body parts press on bony pelvic structures)pelvic structures)

ExtensionExtension:: top of head delivered & extends top of head delivered & extends as as

face & chin are delivered.face & chin are delivered.

External RotationExternal Rotation: head rotates back to : head rotates back to previous lateral position. Rest of body is previous lateral position. Rest of body is delivered.delivered.

Factors affecting labor process: Factors affecting labor process:

4 P’s [Powers of Labor]4 P’s [Powers of Labor]– PassengerPassenger– PassagewayPassageway– PowersPowers– psychepsyche

Passenger: [infant]Passenger: [infant]Fetal headFetal head: widest part of body; most difficult to : widest part of body; most difficult to

pass pass thru vaginal canal; passage depends on bones, thru vaginal canal; passage depends on bones,

sutures, sutures, fontanelles.fontanelles.

Cranium - 8 bones meet @ suture linesCranium - 8 bones meet @ suture linesCranial bones move & overlap, allows skull to pass Cranial bones move & overlap, allows skull to pass

thru birth canal. thru birth canal. Fontanelles: Fontanelles: soft spaces created by soft spaces created by junctures of junctures of

suture lines - covered by membranes; compress suture lines - covered by membranes; compress during delivery to aid in passage of fetus. during delivery to aid in passage of fetus.

““Molding” of infant head.Molding” of infant head.

Passenger contPassenger cont.. Skull widest @ antero-posterior diameter Skull widest @ antero-posterior diameter

[front to back] than @ transverse diameter [front to back] than @ transverse diameter [across]. [across].

Antero-posterior diameterAntero-posterior diameter measures measures differently @ different locations.differently @ different locations.

Occipitomental diameter- widest - measured from Occipitomental diameter- widest - measured from chin to posterior fontanelle = 13.5 cmchin to posterior fontanelle = 13.5 cm

Smallest diameter - lower occiput to anterior Smallest diameter - lower occiput to anterior fontanelle (suboccipitobregmatic) = 9.5 cm fontanelle (suboccipitobregmatic) = 9.5 cm

Complete flexionComplete flexion allows smallest diameter of allows smallest diameter of fetal skull to enter pelvis most easilyfetal skull to enter pelvis most easily..

B.B. Fetal AttitudeFetal Attitude: degree of flexion of fetal : degree of flexion of fetal

head; chin touches sternum. head; chin touches sternum.

Complete flexionComplete flexion: allows smallest diameter : allows smallest diameter of skull of skull

to pass thru pelvic cavity. Best position!to pass thru pelvic cavity. Best position!

Moderate flexionModerate flexion: head less flexed making : head less flexed making

diameter wider (aka military or neutral)diameter wider (aka military or neutral)

Poor flexion:Poor flexion: brow or face presentation; brow or face presentation; presents presents

skull diameter too wide making delivery skull diameter too wide making delivery difficult. difficult.

Friedman’s CurveFriedman’s Curve Friedman's Curve describes progress of two Friedman's Curve describes progress of two

variables over time: dilation of cervix and descent variables over time: dilation of cervix and descent of baby. of baby.

Labor is “dysfunctional” when cervix stops Labor is “dysfunctional” when cervix stops dilating or fetal descent stops dilating or fetal descent stops or both.or both.

Possible diagnosis of "failure to progress" Possible diagnosis of "failure to progress" C-section indicated. C-section indicated. Maybe due to CPD (cephalo pelvic disproportion Maybe due to CPD (cephalo pelvic disproportion

or epidural anesthesia (can slow labor).or epidural anesthesia (can slow labor).

C. Fetal lieC. Fetal lie: [position of fetus in utero] relationship of long : [position of fetus in utero] relationship of long axis of fetus [spine] to long axis of mother: axis of fetus [spine] to long axis of mother:

1. Longitudinal1. Longitudinal – vertex/breech; vertical in – vertex/breech; vertical in relation to mom; ~ 99%. relation to mom; ~ 99%. 2. Transverse 2. Transverse – horizontal in relation to mom; < 1 %.– horizontal in relation to mom; < 1 %. C/S; ^ in grand multip – stretched uterine muscles; try C/S; ^ in grand multip – stretched uterine muscles; try

version.version.3. Oblique - diagonal3. Oblique - diagonal

D. Fetal presentationD. Fetal presentation: part of fetal head enters pelvis; : part of fetal head enters pelvis; 1. Cephalic 95.5%1. Cephalic 95.5%2. Breech 3.5%2. Breech 3.5%3. Face 0.3% 3. Face 0.3% 4. Shoulder 0.4% [transverse lie] 4. Shoulder 0.4% [transverse lie]

E. Fetal positionE. Fetal position: “occiput is landmark”: “occiput is landmark”

Described in 3 lettersDescribed in 3 letters:: 11stst : presenting part in relation to mother: presenting part in relation to mother’’s R or L. s R or L. Middle:Middle: presenting part [occiput, presenting part [occiput, mentum, sacrummentum, sacrum] ] Last:Last: landmark is anterior, posterior, transverse landmark is anterior, posterior, transverse in in

relation torelation to mother mother’’s spine. Anterior (A) back of s spine. Anterior (A) back of head against symphysis pubis & face towards head against symphysis pubis & face towards spine. Posterior (P) Back of head = motherspine. Posterior (P) Back of head = mother’’s s spine; painful contxs. Transverse (T) = fetus spine; painful contxs. Transverse (T) = fetus sideways.sideways.

Common positions in Common positions in vertex presentationsvertex presentations: *LOA, : *LOA, ROT, ROP, ROA, LOT, LOP. ROT, ROP, ROA, LOT, LOP.

Passageway:Passageway:

RRefers to fetus passing thru uterus, cervix, efers to fetus passing thru uterus, cervix, vaginal vaginal

canal.canal. Single most important determinant to Single most important determinant to mechanism mechanism

of labor.of labor.

A. 4 Types of pelvisA. 4 Types of pelvis: : 1. Gynecoid 1. Gynecoid –– 50% of women; rounded, oval 50% of women; rounded, oval

shape; easy vaginal delivery; considered shape; easy vaginal delivery; considered ““normal female pelvisnormal female pelvis””

2. Android 2. Android –– 20 % of women; vaginal delivery 20 % of women; vaginal delivery difficult; prob. C/S; difficult; prob. C/S; ““true male pelvistrue male pelvis””

3. Anthropoid 3. Anthropoid –– oval; assisted vaginal birth usually oval; assisted vaginal birth usually with forceps; 20-25%with forceps; 20-25%

4. Platypelloid 4. Platypelloid –– < 5 % of women; < 5 % of women; flattened pelvis; vag. del. difficult flattened pelvis; vag. del. difficult

B. Structure of PelvisB. Structure of Pelvis:: bones held together bones held together by ligaments. Supports/protects organs by ligaments. Supports/protects organs inside. inside.

False Pelvis: Outer - broader. Hip bones.False Pelvis: Outer - broader. Hip bones.True Pelvis: Internal – narrower. Holds bladder, True Pelvis: Internal – narrower. Holds bladder,

rectum, & reprod. Organs.rectum, & reprod. Organs.

True pelvis - 3 parts - inlet, midpelvis, outlet.True pelvis - 3 parts - inlet, midpelvis, outlet. [Most important in childbirth][Most important in childbirth] If pelvis too small, home birth not done. If pelvis too small, home birth not done. CPD - cephalopelvic disproportion > C/S.CPD - cephalopelvic disproportion > C/S.

PELVIC INLETPELVIC INLET: :

Antero-posterior diameter - front to back ~ Antero-posterior diameter - front to back ~ 12.5 12.5

cm. (diagonal conjugate) cm. (diagonal conjugate)

True conjugate - actual opening of outlet. True conjugate - actual opening of outlet. Subtract width of symphysis pubis [1.5 cm] Subtract width of symphysis pubis [1.5 cm]

from from diagonal conjugate. 12.5 – 1.5 = 11.0 cm.diagonal conjugate. 12.5 – 1.5 = 11.0 cm.(complete flexion = 9.5cm diameter) (complete flexion = 9.5cm diameter)

Transverse diameter [across] ~ 13.5 cmTransverse diameter [across] ~ 13.5 cm

MIDPELVISMIDPELVIS: narrowest part of pelvis that : narrowest part of pelvis that fetus must pass through - “ischial spines”fetus must pass through - “ischial spines”

PELVIC OUTLETPELVIC OUTLET: Trouble passing through : Trouble passing through pelvic opening, pelvis too small or poor pelvic opening, pelvis too small or poor fetal attitude. fetal attitude.

Soft TissueSoft Tissue: : Ligaments, Uterus, Ligaments, Uterus, cervix, cervix, vaginal canalvaginal canal

Powers:Powers: Uterine contxUterine contx’’s: primary force moving s: primary force moving

fetus thru maternal pelvis during 1st fetus thru maternal pelvis during 1st stage of labor.stage of labor.

Maternal Efforts: woman adds voluntary Maternal Efforts: woman adds voluntary pushing force to force of contx.pushing force to force of contx.’’s during s during 2nd stage of labor to propel fetus thru 2nd stage of labor to propel fetus thru pelvis.pelvis.

Psyche:Psyche:Psychologic Response to birth process: Psychologic Response to birth process:

Prepared for childbirth - Childbirth classes-Prepared for childbirth - Childbirth classes-Prenatal care.Prenatal care.

Previous childbirth experience - Complicated?Previous childbirth experience - Complicated? Support from significant other - Separated? Support from significant other - Separated?

Marital strain? FOB involved? Abuse?Marital strain? FOB involved? Abuse? Emotional status - anxious/depressed, drug use, Emotional status - anxious/depressed, drug use,

psych hx psych hx Culture - background may influence response to Culture - background may influence response to

pain. Some moan, some stoic, some verbally pain. Some moan, some stoic, some verbally expressive. expressive.

Fear/anxiety exacerbate pain → uterine Fear/anxiety exacerbate pain → uterine dysfunction & ineffectual labor & posttraumatic dysfunction & ineffectual labor & posttraumatic stress disorderstress disorder

Maternal/Fetal Evaluation Maternal/Fetal Evaluation During LaborDuring Labor With Electronic With Electronic External/InternalExternal/Internal MonitoringMonitoring

EFM “electronic fetal monitoring”EFM “electronic fetal monitoring” Measures:Measures:Fetal Heart Rate (FHR) and Uterine Contractions Fetal Heart Rate (FHR) and Uterine Contractions

(UC)(UC)

External – Toco (UC) and Cardio (FHR)External – Toco (UC) and Cardio (FHR)• Toco transducer uses graph paper [60 sec Toco transducer uses graph paper [60 sec

intervals]intervals] UC assessed for intensity, length, frequency.UC assessed for intensity, length, frequency.• Abdominal palpation. Uterus hard then soft.Abdominal palpation. Uterus hard then soft.

As contractions intensify, labor As contractions intensify, labor progresses.progresses.Vaginal Exam - Vaginal Exam - dilation, effacement, dilation, effacement, station, & presentationstation, & presentation. .

3 Phases of UC:3 Phases of UC: a. increment ↑a. increment ↑ b. acme [peak]b. acme [peak] c. decrement c. decrement

Assessment: Assessment: IntermittentIntermittent - 20 minute tracing standard. - 20 minute tracing standard.Continuous - Continuous - for active labor or with for active labor or with

complications.complications.

Duration: beg. of contx. to end of same Duration: beg. of contx. to end of same contx. Lasts ~ 30 sec. [early] to ~ 60 sec. contx. Lasts ~ 30 sec. [early] to ~ 60 sec. [active].[active].

Frequency: beg. of one contx. to beg. of next.Frequency: beg. of one contx. to beg. of next.~ q 5 -30 min. ~ q 5 -30 min. earlyearly labor; q 2-3 min. labor; q 2-3 min. activeactive

labor.labor.

Resting Tone: period of uterine rest bet. Resting Tone: period of uterine rest bet. contx.contx.’’s. s.

Measure by palpation; internally Measure by palpation; internally measures ~10 measures ~10 mmHg.mmHg.

Be Careful Not ToBe Careful Not To….…. Rely on verbal clues from mother Rely on verbal clues from mother

regarding contractions & labor regarding contractions & labor progress.progress.

Misleading, giving false impression of Misleading, giving false impression of good labor pattern. good labor pattern.

Contractions may be more or less Contractions may be more or less intense than what pt. reports. intense than what pt. reports.

RN may miss forceful contractions d/t RN may miss forceful contractions d/t excellent coping skills or high pain excellent coping skills or high pain tolerancetolerance

External Fetal MonitoringExternal Fetal Monitoring

AlsoAlso Records Records: : Fetal Heart Rate (cardio transducer) FHRFetal Heart Rate (cardio transducer) FHR

AdvantagesAdvantages: : Evaluates contractions & FHREvaluates contractions & FHRProvides written record of bothProvides written record of both

DisadvantagesDisadvantages: : May be May be inaccurateinaccurate due to maternal/fetal due to maternal/fetal

movements.movements.Need experienced clinician to read otherwise Need experienced clinician to read otherwise

info info can be misinterpreted. can be misinterpreted.

Internal Monitoring Internal Monitoring More Accurate More Accurate !! Fetal scalp electrodeFetal scalp electrode: wire electrode attached to : wire electrode attached to

scalp of fetus -monitors FHR accurately & scalp of fetus -monitors FHR accurately & continuouslycontinuously. .

Advantages: precise assessment of FHR; not Advantages: precise assessment of FHR; not affected by fetal movement.affected by fetal movement.

Disadvantages: lacerations of fetal scalp, mom Disadvantages: lacerations of fetal scalp, mom cancan’’t ambulate. t ambulate.

IUPC -intrauterine pressure catheter inserted into IUPC -intrauterine pressure catheter inserted into uterine cavity to monitor contx.’s uterine cavity to monitor contx.’s precisely/continuously.precisely/continuously.

Advantages: precise assessment of maternal Advantages: precise assessment of maternal contractions. Mom can turn side to side.contractions. Mom can turn side to side. Measures Intensity: “strength” of UC internally Measures Intensity: “strength” of UC internally [30-50mmHg during peak of contx][30-50mmHg during peak of contx]

Disadvantages: ↑ risk of maternal infection, mom can’t Disadvantages: ↑ risk of maternal infection, mom can’t ambulate.ambulate.

Fetal Heart RateFetal Heart Rate

““BaselineBaseline”” average fetal heart rate that average fetal heart rate that occurs between contx.occurs between contx.’’s during 10 min. s during 10 min. period.period.

Normal 110/120 - 160 [accels/decels not Normal 110/120 - 160 [accels/decels not counted]counted]

BradycardiaBradycardia –– FHR < 110 for 10 minutes; FHR < 110 for 10 minutes; <100bpm sign of fetal hypoxia; danger sign.<100bpm sign of fetal hypoxia; danger sign.

Seen with prolapsed cordSeen with prolapsed cord

TachycardiaTachycardia –– FHR > 160 for 10 minutes. FHR > 160 for 10 minutes. assoc. with maternal temp. and infection such as assoc. with maternal temp. and infection such as chorioamnionitis.chorioamnionitis.

Variability [FHR] aka “Baseline Variability [FHR] aka “Baseline Variability”Variability”

““Fluctuations” in FHR. Normal & expected Fluctuations” in FHR. Normal & expected finding. finding. Should always be present; appears as Should always be present; appears as “jitters”. “jitters”.

Clinical Significance- Clinical Significance- fetal well-beingfetal well-being.. Caused byCaused by natural pacemaker ability natural pacemaker ability of FH of FH

d/t effects of sympathetic & d/t effects of sympathetic & parasympathetic nervous system.parasympathetic nervous system.

Nursing Interventions- cont. monitoring & Nursing Interventions- cont. monitoring & assess tracing q 15 min. Should show 6-25 assess tracing q 15 min. Should show 6-25 bpm fluctuations within one min. period. bpm fluctuations within one min. period.

120 → 135 “reassuring” 120 → 135 “reassuring”

Main Causes of decreased variability include:

Hypoxemia/acidosis (due to fetal distress)Fetal sleep cyclesDrugs (Analgesics, barbiturates, tranquilizers, anesthetics)PrematurityArrhythmiasFetal tachycardiaPreexisting neurological abnormalityCongenital anomalies

Decreased variability of FHRDecreased variability of FHR

Nursing Interventions:Nursing Interventions: * accoustic stimulation to “wake” fetus * accoustic stimulation to “wake” fetus * Narcan * Narcan * Amnioinfusion - decreases cord comp; dilutes * Amnioinfusion - decreases cord comp; dilutes

mec. mec. * Left/right lateral position or knee-chest; notify * Left/right lateral position or knee-chest; notify

MD; MD; fetal scalp pH, possible emergency C/S; IVF, O2 fetal scalp pH, possible emergency C/S; IVF, O2 ““Flat tracing” or “minimal” aka non-reactive tracing Flat tracing” or “minimal” aka non-reactive tracing

[pencil mark pattern] indicates fetal distress; [pencil mark pattern] indicates fetal distress; must be corrected or delivered ASAP. Experienced must be corrected or delivered ASAP. Experienced RN usually able to determine reason for non-RN usually able to determine reason for non-reactive tracing.reactive tracing.

How Do Uterine Contractions Affect Fetal Heart Rate?

Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction.

The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of:

· Fetal head compression

· Umbilical cord compression

· Uterine myometrial vessel compression

Decelerations: decreases in FHR. Decelerations: decreases in FHR.

Early deceleration of FHR- periodic ↓ in FHREarly deceleration of FHR- periodic ↓ in FHR Cause = head compression during contx.Cause = head compression during contx. ’’ss Shape= onset of decel to peak > than 30 Shape= onset of decel to peak > than 30

sec.sec. Nadir of decel (lowest point) & peak of contx. Nadir of decel (lowest point) & peak of contx.

(highest point) coincide. Mirror image of contx.(highest point) coincide. Mirror image of contx. Range= lasts as long as contx.; resolves with end Range= lasts as long as contx.; resolves with end

of contx. Occurs late in labor when head has of contx. Occurs late in labor when head has descended.descended.

Clinical Significance= normal; if it occurs early in Clinical Significance= normal; if it occurs early in labor before head fully descends, may be labor before head fully descends, may be indication for cephalo-pelvic disproportion [CPD].indication for cephalo-pelvic disproportion [CPD].

Late deceleration of FHR:Late deceleration of FHR:

Cause= uteroplacental insufficiency or ↓ Cause= uteroplacental insufficiency or ↓ blood flow thru uterus during contx.blood flow thru uterus during contx.’’ss

Shape Shape –– nadir of decel. occurs > end of nadir of decel. occurs > end of contx.contx.

range - occur 30-40 seconds > contx. range - occur 30-40 seconds > contx. starts & continue > contx. endsstarts & continue > contx. ends

clinical significance clinical significance ––needs immediate needs immediate attention; possible fetal distress. Could be attention; possible fetal distress. Could be d/t pitocin that is causing hypertonic d/t pitocin that is causing hypertonic uterus.[ too many contx.- no time for uterus.[ too many contx.- no time for recovery]recovery]

Nursing Interventions:Nursing Interventions:

-Left lateral position -Left lateral position –takes –takes pressurepressure

off aorta & vena cava; ↑circulation off aorta & vena cava; ↑circulation toto

uterus.uterus.

-↑ IV flow rate -↑ IV flow rate ––↑ Circulation↑ Circulation– oxygen - face mask [5liters/min].oxygen - face mask [5liters/min].– D/C pitocin & documentD/C pitocin & document– assist with fetal blood sampling assist with fetal blood sampling – [measures acidosis in fetus which [measures acidosis in fetus which

signifies hypoxia]signifies hypoxia]– Prepare for emergency C/S if Prepare for emergency C/S if

decels. persistdecels. persist

Variable deceleration of FHRVariable deceleration of FHR

Cause: compressed umbilical cordCause: compressed umbilical cord

Shape Shape –– U or V shaped waves in FHR U or V shaped waves in FHR

Range Range ––no pattern; occur in relation to no pattern; occur in relation to contx.contx.’’s s

Clinical Significance Clinical Significance –– fetus lying on cord; fetus lying on cord; could be could be

dangerous if persist. dangerous if persist.

Occurs more > ROM [less fluid as cushion]Occurs more > ROM [less fluid as cushion]

V = C variable decels = cord compressionV = C variable decels = cord compression

E = H early decels = head compressionE = H early decels = head compression

A = O accelerations = OKA = O accelerations = OK

L = P late decels = Placental insufficiencyL = P late decels = Placental insufficiency

Bradycardia = R/O prolapsed cord Bradycardia = R/O prolapsed cord [emergency]![emergency]!

Nursing InterventionsNursing Interventions– oxygen via face mask; IV fluidsoxygen via face mask; IV fluids– change maternal position; take pressure change maternal position; take pressure

off cordoff cord– continue monitoring w.EFMcontinue monitoring w.EFM– follow hospital protocol: MD will do follow hospital protocol: MD will do

amnioinfusion > ROM to supplement amnioinfusion > ROM to supplement amniotic fluid thatamniotic fluid that’’s left; provides fluid s left; provides fluid barrier to prevent further cord barrier to prevent further cord compression.compression.

Sterile, warm 500 ml NS/RL inserted into uterus Sterile, warm 500 ml NS/RL inserted into uterus EFM observed for improved FHR pattern.EFM observed for improved FHR pattern.

4.4. Accelerations of FHR Accelerations of FHR: : temporary abrupt temporary abrupt increase in FHR above normal baseline.increase in FHR above normal baseline.

cause- fetal movement; cause- fetal movement; contractions *contractions * shape-FHR rises w. return to baseline; can occur shape-FHR rises w. return to baseline; can occur

@ same time as contx. or independently.@ same time as contx. or independently. Premie < 32 wks.; 10 bpm rise lasting 10 sec. okPremie < 32 wks.; 10 bpm rise lasting 10 sec. ok 32 wks. or >, 15 bpm rise baseline lasting 15 sec. 32 wks. or >, 15 bpm rise baseline lasting 15 sec.

ok ok ex. 135 ↑ to 150’s for 30 seconds.ex. 135 ↑ to 150’s for 30 seconds. clinical significance: normal; signifies fetal well-clinical significance: normal; signifies fetal well-

being. FHR meeting demands of labor process being. FHR meeting demands of labor process well.well.

Fetal Blood Sampling- assesses fetal hypoxia; from Fetal Blood Sampling- assesses fetal hypoxia; from fetal scalp [cervix dilated 3-4 cm]. Clean scalp w. fetal scalp [cervix dilated 3-4 cm]. Clean scalp w. iodine. iodine.

Results: 7.25ph > normalResults: 7.25ph > normal 7.20 -7.24 preacidotic7.20 -7.24 preacidotic< 7.2 + acidosis; indicates hypoxia [↓ O2]< 7.2 + acidosis; indicates hypoxia [↓ O2] Role of Coach in Labor & DeliveryRole of Coach in Labor & Delivery

– emotional supportemotional support– physical support – touch, massage physical support – touch, massage – reduce anxietyreduce anxiety– bonding with newborn as a couplebonding with newborn as a couple

Obstetrical Procedures Obstetrical Procedures

Episiotomy: Episiotomy: incision on perineum to incision on perineum to enlarge vaginal outlet. enlarge vaginal outlet. New trend: not New trend: not

done routinely. done routinely. (in 2(in 2ndnd stage) stage)

Types: Types: Median Median ––vertical incision. vertical incision. Medio-lateral Medio-lateral ––slanted to R/L of perineum; slanted to R/L of perineum;

done done if tear anticipated. if tear anticipated. Advantages: Advantages: median or midline epis.median or midline epis.medio-lateral prevents tearing towards medio-lateral prevents tearing towards rectum. Less chance of laceration. rectum. Less chance of laceration. Disadvantages: Disadvantages: medio-lateral -longer medio-lateral -longer to heal.to heal.

Forceps: Forceps: double bladed instrument to assist double bladed instrument to assist passage of fetus. Not routinely done today. passage of fetus. Not routinely done today.

When 2nd stage labor has stopped d/t epidural When 2nd stage labor has stopped d/t epidural Infant in abnormal position; posterior position in Infant in abnormal position; posterior position in

birth canal; macrosomia.birth canal; macrosomia.

[Outlet] Low forcep delivery: fetal head @ + 2, +3 [Outlet] Low forcep delivery: fetal head @ + 2, +3 station. Some anesthesia used. station. Some anesthesia used.

Midforceps & High forceps: not done ^ birth Midforceps & High forceps: not done ^ birth trauma. trauma.

Cervical lacerations; Newborns > facial palsy or Cervical lacerations; Newborns > facial palsy or subdural hematoma; forcep marks on face.subdural hematoma; forcep marks on face.

Vacuum Assisted DeliveryVacuum Assisted Delivery: : disk shaped cup placed on scalp & vacuum disk shaped cup placed on scalp & vacuum pressure applied; pressure applied; ““pullpull”” will deliver infant. will deliver infant. No anesthesia - fewer cervical lacerations. No anesthesia - fewer cervical lacerations. Not done in preterm infants d/t soft skull.Not done in preterm infants d/t soft skull.Used in C/S.Used in C/S.

Not used > scalp pH done; risk for Not used > scalp pH done; risk for hematoma [vacuum pressure].hematoma [vacuum pressure].

Can cause caput for ~ 1 wk. Used Can cause caput for ~ 1 wk. Used w.macrosomia.w.macrosomia.

VBACVBAC [vaginal birth after cesarean] [vaginal birth after cesarean]

OK after low abd. incision; Not after classical OK after low abd. incision; Not after classical incision - risk for uterine rupture. incision - risk for uterine rupture.

New Trend: not routinely done anymore. ** Pros & New Trend: not routinely done anymore. ** Pros & cons cons

1st baby:1st baby: breech, fetal distress, pre- breech, fetal distress, pre-eclampsiaeclampsia

Should space deliveries ~18 mos. apart. to Should space deliveries ~18 mos. apart. to prevent ruptureprevent rupture

Types of Uterine IncisionsTypes of Uterine Incisions::

Low transverse = Pfannenstiel = Low transverse = Pfannenstiel = ““bikini cutbikini cut””. . Most desired & less visible. Right above pubic Most desired & less visible. Right above pubic bone.bone. Vertical=classical incision. Visible scar; Vertical=classical incision. Visible scar; emergency emergency cases; cases; ““crashcrash”” C/S. Quick access to baby. C/S. Quick access to baby.

Cesarean DeliveryCesarean Delivery ( C-section) ( C-section)Major Indications for C/S:Major Indications for C/S:

Active genital herpes or overgrowth of genital Active genital herpes or overgrowth of genital wartswarts

HIV infectionHIV infection CPD (cephalopelvic disproportion)CPD (cephalopelvic disproportion) Severe HTN (toxemia)Severe HTN (toxemia) Failure to progress with laborFailure to progress with labor Previous C/S with classical incision (vertical)Previous C/S with classical incision (vertical) Placenta previaPlacenta previa Placental abruption –separation of placenta from Placental abruption –separation of placenta from

uterusuterus Cord Prolapse; Macrosomia = large fetusCord Prolapse; Macrosomia = large fetus Breech positions; Fetal Distress & Transverse Breech positions; Fetal Distress & Transverse

fetal liefetal lie

Induction of Labor:Induction of Labor: start labor. start labor. Goal: Goal: NSVDNSVD

Without Meds.- NaturalWithout Meds.- NaturalAmniotomy: Artificial ROM; amnio hook; Amniotomy: Artificial ROM; amnio hook;

break sac.break sac.Monitor for poss.prolapsed cord. Monitor for poss.prolapsed cord. Continue EFM. Usu.starts contx.Continue EFM. Usu.starts contx.’’s & labor s & labor

progresses [@ 3 cm dilation]progresses [@ 3 cm dilation]

With MedsWith Meds.. Pitocin drug of choice. 1/3 rd deliveries @ Pitocin drug of choice. 1/3 rd deliveries @ term in US done by induction. Reason: term in US done by induction. Reason: Life in uterus no longer Life in uterus no longer beneficial beneficial

*Fetal maturity 39 wks, post dates 41-42 wks.*Fetal maturity 39 wks, post dates 41-42 wks. *Cervical Readiness- ripe; ≥3 cm. dilated.*Cervical Readiness- ripe; ≥3 cm. dilated. *Longitudinal lie; presenting part engaged*Longitudinal lie; presenting part engaged *Fetal Demise, Arrest of Labor *Fetal Demise, Arrest of Labor

Induction - give Pitocin IVPB, ^ slowly as labor Induction - give Pitocin IVPB, ^ slowly as labor progresses; shut off if contxprogresses; shut off if contx’’s too strong. Need MDs too strong. Need MD order.order.

Augmentation:Augmentation: assisting assisting labor thatlabor that’’s in s in

progress. Pitocin used. progress. Pitocin used.

Contraindications:Contraindications:Maternal: placenta previa; active herpes; Maternal: placenta previa; active herpes;

structural abnormalities; previous vertical structural abnormalities; previous vertical uterine scaruterine scar

Fetal: transverse or breech; fetal distress; Fetal: transverse or breech; fetal distress; premie. premie.

Nursing Interventions: Nursing Interventions:

IVF 10 units Pitocin in 1000 ml. RLIVF 10 units Pitocin in 1000 ml. RL Start rate @ 1 milliunit/min - pump Start rate @ 1 milliunit/min - pump Gradually ↑ to establish effective contx. patternGradually ↑ to establish effective contx. pattern Monitor UC for frequency, rate, intensity Monitor UC for frequency, rate, intensity Monitor FHR for signs of fetal distressMonitor FHR for signs of fetal distress Maternal BP, pulse, tempMaternal BP, pulse, temp I&OI&O Notify MD of progressNotify MD of progress Chart q 15 min on graph Chart q 15 min on graph Prepare for delivery: radiant warmer, O2, Prepare for delivery: radiant warmer, O2,

suctioning, suctioning, Hyper-stimulation of uterus; shut off pitocin as Hyper-stimulation of uterus; shut off pitocin as

per MD.per MD.

Bishop’s score: Bishop’s score: determines determines cervical readinesscervical readiness for for

induction; looks at 5 factors. Score ≥ 8 favorable.induction; looks at 5 factors. Score ≥ 8 favorable.

Multip can be induced @ 5 Multip can be induced @ 5 Primip can be induced @ 7 Primip can be induced @ 7

Uterus/cervix should respond to induction. Uterus/cervix should respond to induction. Score < 5 low probability of success. Ripen cervix 1st. Score < 5 low probability of success. Ripen cervix 1st.

Bishop Scoring SystemBishop Scoring System - evaluates cervical readiness - evaluates cervical readiness

for induction. 5 elements measured:for induction. 5 elements measured:

Score Cervical Cervical Station Cervical Position Score Cervical Cervical Station Cervical Position

dilation effacement consistencydilation effacement consistency

_______cm.________%______________________________________cm.________%_______________________________

0 closed 0-30 -3 firm posterior0 closed 0-30 -3 firm posterior

1 1-2 40-50 -2 medium mid 1 1-2 40-50 -2 medium mid

2 3-4 60-70 -1, 0 soft anterior 2 3-4 60-70 -1, 0 soft anterior

3 >5 >80 +1, +2 3 >5 >80 +1, +2

Cervical Ripening: Cervical Ripening: Artificial softening of cervix Artificial softening of cervix before before laborlabor. . Prostaglandin gel 0.5mg.or dinoprostone Prostaglandin gel 0.5mg.or dinoprostone 10mg.=[cervidil] 10mg.=[cervidil] 2-3 times q 12 for max. of 24 hrs. 2-3 times q 12 for max. of 24 hrs. * Done if cervix “unripe” or thick & undilated. * Done if cervix “unripe” or thick & undilated.