Professional Documents
Culture Documents
Labor and Delivery
Labor and Delivery
Intrapartum
From
onset of contractions, dilation of cervix up to first 4 hours after delivery products of conception are expelled
All
LABOR
Fetal
expulsion along with products of conception due to: regular, progressive & frequent uterine contractions
Parturient
LABOR ONSET
a. b.
c.
d. e.
Stretching of uterine muscles progesterone Release of oxytocin Maturity of placenta prostaglandin Contraction of Uterus Expel products of conception
TRUE LABOR
Pain = Back discomfort radiating to abdomen & legs Intensified by Walking Bloody show
4 Stages of Labor
1. First Stage onset of true labor to complete dilation 2. Second stage complete cervical dilation to delivery 3. Third Stage placental stage 4. Fourth Stage first 4 hours after delivery of placenta
1. Passageway (Pelvis)
leaving the uterus Ischial spines = degree of descent (station) of fetal head Above ischial spine - station Floating (unengaged) Ischial spine station 0; engaged Below ischial spine + station
maternal pelvis Route of fetus when
Pubis = front portion = 2 pubic bones meet at symphysis pubis Estrogen & Relaxin = Relaxes the symphysis pubis Slight separation allowing room for the fetal head
1.
3. Platypelloid - Normal female pelvis - Flat - Round & wide - Good vaginal delivery - Poor vaginal delivery
2. Anthropoid - Narrow, oval - Like ape pelvis - Good Vaginal Delivery
Gynecoid
Pelvic Types
2. Passenger
Refers to fetus Fetal head
consists of :
parietal)
occipital bones)
3. POWER
contractions
PRIMARY POWER
Uterine
SECONDARY POWER
Maternal
contractions
bearing
pressure
Uterine Contractions (primary power) - wavelike manner Phases of Intensity: Increment intensity - builds up & longest phase Acme contraction is at its strongest - peak of contraction Decrement intensity - letting down phase
a.
Sense the gradual tensing and upward rising of fundus that accompanies a contraction.
Mild minimally tense. - indented easily with fingertips Moderate feels firm; fundus is difficult to indent
Strong so intense; uterus feels hard as wooden board at peak of contraction - Fundus is firm, cant be indented with fingers
Duration beginning to end of same contraction - Seconds - Report if more than 90 sec - During transition phase (2nd stage of labor)
Frequency - beginning of 1 contraction to beginning of next contraction. - Minutes; Report if less than 2 minutes 2 parts: 1. Duration of contraction 2. Period of relaxation
Interval
Dilatation Widening of cervical canal - Advances from 0 10cm - As cervical canal opens = resistance - This eases fetal descent - 10 cm = fully dilated
Effacement
Thinning, shortening of cervical canal Expressed in % 100% effaced cervix = cervical canal is paper thin or absent 75% = cervix is of its original length 50% = cervix is of its original length
b. Intra-abdominal pressure
This As
Patient Monitoring
Void
Frequently
4. Placenta
Placental Separation Calkins sign = Uterus becomes globular & firm Fundus of uterus rises in the abdomen Umbilical cord lengthening Gush of blood from the vagina
Placental Expulsion Natural bearing down of the mother Gentle pressure on contracting uterus (Credes maneuver) Brandt andrews maneuver downward sideways gentle controlled cord traction
Credes Maneuver
Separates at its edges Umbrella shaped Maternal surface exposed Rough, red, raw & irregular from ridges
After placenta is delivered = veins in the place of attachment at decidua is 7cm dilated = mother is prone to hemorrhage MUST promote contraction after delivery Average blood loss = 250-300 ml 500 ml or above = postpartal hemorrhage (maternal mortality)
Amniocentesis
- couvade syndrome Pap smear - placenta FHR - probable sign Leopolds - amniotic fluid Pregnancy test - fetal distress Prenatal visit - smoke effect to NB Primipara & primigravida - TT Morning sickness - foods rich in folic acid Hyperemesis gravidarum - exercise for back pain Quickening - iron supplement Uti - foods rich in iron Weight gain - varicose veins
Leg
cramps - dyspnea Constipation - Johnsons rule Iodine rich foods - bartholomews rule Heartburn/pyrosis - naegeles rule Anemia - haases rule Kegels exercise - mc donalds rule Clothes for pregnant women - incidence of twins Vaginal secretions/leukorrhea - lightening Urinary frequency - mesoderm Alcohol - products of conception Teratogen - sequence of conception Type of exercise - implantation
Cocaine
- dilation AVA - effacement Fetal attitude - break BOW Fetal presentation - VBAC Fetal position - types of placenta Fetal station - advantage of episiotomy Pelvic shape - breech presentation Position for vaginal delivery - types of breech Cardinal movements of labor - intensity, duration, Crowning interval, frequency Laceration - TPAL Placental separation - 4 stages of labor
Pain
during labor accompanies: uterine contractions cervical dilatation & effacement fetal descent
Response
Nonpharmacologic measures
Read Method Slow abdominal breathing in 1st stage of labor: 1 breath/minute (30 sec inhalation & 30 sec exhalation)
Lamaze
Leboyer Method environment Room is darkened Pleasantly warm with soft music playing Focusing, Relaxation & Positioning obstruction Concentrate on photograph or object during contractions
Imagery
For
Distraction Diversion of attention - early labor Playing games or recalling pleasant experiences Yoga Deep-breathing exercises, body stretching postures and meditation
Acupuncture stimulation of trigger points with needles - release of endorphins to reduce pain
a.
a. Opioids
Commonly
adverse reaction: Respiratory depression Nausea & vomiting Drowsiness Transient hypotension
b. Sedatives
Barbiturates
- used in early latent phase of labor secobarbital (seconal) pentobarbital (Nembutal) midazolam (Versed)
Benzodiazepines
c. Regional Aesthesia
patient awake & cooperative in delivery Provides analgesia for the 1st & 2nd stages of labor & anesthesia for birth
Epidural animation
Spinal Anesthesia injected at cerebrospinal fluid (CSF) at Lumbar 3-4 Hypotension can occur Spinal headache Increase incidence of urinary retention Local anesthesia during actual birth of the fetus
injection into perineal nerves receives relief from discomfort only at delivery not during labor
Nursing Interventions
Know
Allay
Assist
monitor adverse
Fetal Lie Fetal Attitude Fetal Presentation Fetal Position Fetal Station
1. FETAL PRESENTATION
Describes
fetal body part to pass thru cervix and be delivered part felt on IE
The
I. Cephalic Presentation Head presents first at the cervix Vertex presentation Sinciput/forehead presentation Brow presentation Mentum/Face presentation
Vertex
Sinciput/Forehead
the chest
alert or military position Anterior fontanel (bregma) Fetal Attitude: Moderate flexion
complete/full flexion
Brow
head
Mentum/Face
fetal head is
is moderately extended
hyperextended
brow Fetal
enters first
diameter
Fetal Attitude:
Complete extension
During labor, the fetal skull press cervix becomes edematous from continued pressure against it.
II. Breech Presentation either buttocks/feet are first to contact the cervix
3 Types:
Complete
Frank
Footling
buttocks
hips are flexed but legs are extended, resting on chest to present first
buttocks
Cord prolapse is common because of the extended leg Cesarean birth may be necessary
In
breech presentation =
passage
PINARD MANEUVER
MAURICEU MANEUVER
PRAGUE MANEUVER
III. Shoulder Presentation presenting part is the shoulder, iliac crest, hand or elbow
transverse lie fetus must be turned before delivery; successful if fetus is small or preterm
extremity prolapses alongside the major presenting parts 2 presenting parts appear at pelvis
2. Fetal Lie
Relationship
of (spine) of the fetus to the (spine) of the mother Can be: I. Longitudinal II. Transverse III. Oblique
The fetus is lying sideto-side If labor progresses, the presenting part may be a shoulder, iliac crest, hand or elbow
Longitudinal
Transverse
fetal spine is 45 angles to maternal spine between transverse and longitudinal lies if fetus maintains this
midway
abnormal
position
3. Fetal Attitude
Degree of flexion
Could be:
I.
Complete/Full Flexion II. Moderate Flexion III. Partial Extension IV. Complete Extension
I. Complete/Full Flexion
Most common
vertex presentation
ideal attitude
occupies smallest space in the uterus
sinciput/forehead presentation
brow presentation
face presentation
Neck is extended
Head is moved backward cause a difficult delivery
A Vertex presentation & Complete flexion B Forehead presentation & Moderate flexion C Brow presentation & Partial extension D Face presentation & Complete extension
4. Fetal Position
Relationship
Landmarks
O = Occiput, vertex presentation M = Mentum, face presentation Sa = Sacrum, breech presentation A = Scapula/ acromion process, shoulder presentation
- Quadrants
R = right L = left A = anterior P = posterior T = transverse (center)
Fetal
position is described by using 3 letters 1st letter = if presenting part facing mothers R or L 2nd letter = presenting part of fetus 3rd letter = if presenting part is pointing to A, P or T of mother's pelvis
Vertex Presentations
ROA ROT Right
ROP
LOA
LOT
LOP
occiput anterior Right occiput transverse Right occiput posterior Left occiput anterior Left occiput transverse Left occiput posterior
Face Presentations
RMA RMT Right
mentum anterior
RMP
LMA Left
mentum anterior
LMT
LMP
Breech Presentations
RSaA RSaT Right
sacrum anterior
RSaP
LSaA Left
sacrum anterior
LSaT
LSaP
LOA & ROA occiput is towards the front; face is down; favourable delivery position
LOP & ROP occiput is towards the back; face is up; much back discomfort, labor is slow
5. Fetal Station
Floating (High) unengaged above ischial spines minus station (-1 to -4 cm)
Determined (IE)
Station 0 = level of the ischial spines
engagement occurs
Phase Phase 1
Station 0 to +2
Phase 2
+2 to +4
2 2.5 min apart with urgency to bear down 1 2 min apart; fetal head visible increased urgency to bear down
Phase 3
+4 to birth
Stages of Labor
1. First Stage onset of true labor to complete dilation 2. Second stage complete cervical dilation to delivery 3. Third Stage placental stage 4. Fourth Stage first 4 hours after delivery of placenta
6-18
Phase
Dilatation
Duration/Interval
Intensity
Latent Phase
Active Phase
Transition Phase
Cervical dilation
Quiet surroundings
Back rubs Pillow support Position changes Offer liquids/ice chips Provide ointment for dry lips
Provide privacy Monitor contractions by palpation/ progress of labor (frequency, duration & intensity)
Assess color of amniotic fluid; meconium staining = fetal distress
Perineal preparation Render enema if ordered: to prevent infection, retardation of labor progress
strong 60 90 seconds every 2-3 minutes 40 minutes average 20 contractions 20 minutes average 10 contractions
Increase
Check for rupture of membranes: time, color, odor, amount and consistency of amniotic fluid Assess signs of hypotensive supine syndrome - If BP falls, position patient on her Left side - Increase IV flow rate - Administer O2 through face mask at 6-10 L/min
When
Primigravida: Cervix 10cm with bulging & contractions Multigravida: Cervix 8-9cm
Assist
mother in positioning: dorsal recumbent for bearing down lithotomy if with position
Check
Prolapsed Cord
Prepare
for birth & maintain sterile technique legs simultaneously in stirrups preparation: front to back
Place
Perineal After
delivery, cord is clamped and cut within 15~20 seconds. Delayed cord clamping can result in hyperbilirubinemia = additional blood is transferred to NB.
I. Engagement II. Descent III. Flexion IV. Internal Rotation V. Extension VI. External Rotation VII. Expulsion
I. Engagement
II. Descent
III. Flexion
rotation of head to pass thru ischial spines head rotates about 45 Fetal head is against the front of her pelvis
V. Extension
head needs to externally rotate to realign with the spine the anterior shoulder descends first
body
of fetal
head
When
time
PD
birth
certificate = legal document must be complete & accurate, devoid of any erasures
procedures
employed to present trauma/reduce hazard to mother and or infant during the birth process.
First degree:
Second degree: subepithelial tissues of the vagina/perineum & muscles of the perineum Third degree: anal sphincter
the pressure on fetal head that accompanies birth easily & heals faster
repaired
Method
Done
during contraction as the babys head pushes against perineum and stretches it. scissors are used
Blunt
Client
Type of Episiotomy: a. Midline episiotomy - center of perineum toward anal sphincter - Easier healing, decreased blood loss & decreased postpartum discomfort - Danger of extension into anal sphincter
b. Mediolateral episiotomy - midline and then angled (45) to 1 side away from the rectum - Decreased risk of rectal mucosa tearing
Blood loss is greater Healing process is quite painful Incision is harder to repair
Forceps delivery Forceps are steel instruments to assist with delivery and relieve fetal head compression 2 blades connected together; blades are slipped into position one at a time Commonly used forceps: Kjellands, Elliot, Piper, TuckerMcLean, Simpsons
For forceps delivery to be performed, the ff must be present: Ruptured membranes Fully dilated cervix Empty bladder Fetal head engaged in maternal pelvis FHT present before and after forcep application Absence of cephalopelvic disproportion It shortens 2nd stage of labor
Indications: Fetal distress Poor progress of fetus through the birth canal Failure of the head to rotate Maternal disease or exhaustion Client is unable to push(with regional anesthesia)
Types:
Low or Outlet presenting part on perineal floor
Disadvantage perinatal morbidity & mortality neonatal birth trauma & depression incidence of perineal lacerations, postpartum hemorrhage & bladder injury
Vacuum extraction An alternative to forceps delivery Facilitates descent of fetal head A plastic vacuum cup is applied to the fetal head, negative pressure is exerted & traction is applied to deliver the head
Advantages Lower incidence of vaginal, cervical & laceration Less maternal discomfort because the cup does not occupy additional space in the birth canal Little anesthesia needed Neonate born with less respiratory depression
Disadvantages Marked caput succedaneum of neonates head lasting as long as 7 days after birth Preterm neonates is problematic because of extreme softness of their skulls
of placenta
several minutes
Duration: 5 30 minutes
Placental Separation Calkins sign = Uterus changes from discoid to globular & from soft to firm
Placental Expulsion
Natural bearing down of the mother Gentle pressure on contracting uterus (Credes maneuver) Brandt andrews maneuver downward sideways gentle controlled cord traction
Fundus of uterus rises in the abdomen Umbilical cord lengthening Gush of blood from the vagina
Separates at its edges Umbrella shaped Maternal surface exposed Rough, red, raw & irregular from ridges
After placenta is delivered = veins in the place of attachment at decidua is 7cm dilated = mother is prone to hemorrhage MUST promote contraction after delivery Average blood loss = 250-300 ml 500 ml or above = postpartal hemorrhage (maternal mortality)
wait DO
NOT do fundal pressure with pull at the cord if uterus is relaxed = could cause hemorrhage
Gradual
Complete
cotyledons (oxygen reserve during 2nd stage of labor to prevent fetal distress) Complete cord vessels: 2 arteries & 1 vein Complete membranes Monitor maternal vital signs inspect cervix and vagina for laceration
Feel fundus for contractions or firmness. soft, boggy & non-palpable = uterine atony
20 units oxytocin IV or p.o. as ordered to enforce contractions Introduce NB to patient & her partner
Immediate & thorough drying 2. Skin to skin contact 3. Properly timed cord clamping & cutting 4. Early BF
1.
c.
Long cord cord coil or cord prolapse 2 vessel cord congenital heart problem; check for AVA
extrauterine life maternal-neonate bonding Uterine contractions prevents bleeding from placental site
Interventions
Asses mother: Every 15 min = 1st four Every 30 minutes = another hour Every hour = 2 hours Ice cap to contract uterus Apply ice pack to perineum if with episiotomy or laceration, swollen uterine massage to keep it firm
Perineal
pad saturated in 15 minutes or blood pooling under buttock = excessive blood loss red lochia = laceration of cervix or vagina
Bright
Check
MIO
Parameter
Rubra
Color
Red
Amount
Moderate
Scanty
Slight
Duration of Labor
Labor Stage
First Stage: true labor full dilatation 1. Latent phase (0 3cm) 2. Active phase (4 7cm) 3. Transitional (8-10cm) Second stage: (full dilatation to birth) Most difficult for fetus Third Stage: (placental expulsion) Fourth stage: (recovery/ immediate postpartum) Dangerous for the mother - Due to hemorrhage
mild & short (20-40 sec) 6 hrs - primi 4-5 hrs - multi
INDUCTION OF LABOR
Artificial initiation of Labor
Fetus
in Longitudinal lie Cervix is ripe or ready for birth Presenting part is engaged No CPD Fetus is mature, mother at or near term No contraindications for use of oxytocin like CS scar, placenta previa
19 2
19 3
Management
- on bedrest - VS & FHT every 15 minutes - IV 10u Pitocin add D5W piggybacked to main line Stop oxytocin if: FHT is more than 170 bpm less than 120 bpm Meconium passage Maternal hypotension
-
19 4
IF FETAL DISTRESS DEVELOPS: a. Stop oxytocin b. Turn client to the left side c. Administer oxygen per mask d. Refer to the physician
Cesarean Birth
Removal of NB from uterus thru abdominal & uterine incision Indicated for: CPD Uterine dysfunction Malposition Previous uterine surgery Placenta previa DM, cardiac disease Prolapsed umbilical cord Fetal distress
Types of Incision
a.
Low Segment Transverse incision - bikini incision - above pubic hairline - Blood loss is minimal - less likely to rupture during future labors due to minimal active contractions at the area - Vaginal delivery may be possible VBAC
b. Classic/vertical incision - vertical incision - used if with previous CS exist - fetus is in transverse lie - chance of vaginal birth is low - because incisions location is in the active contracting portion of uterus
PRE-OPERATIVE Regular preparation for abdominal / pelvic surgery POST-OPERATIVE Ensure airway (suction & oxygen)
Clear liquids after flatus Oxytocic drugs = ensure firm fundus Analgesic = relief of pain Antibiotics = prevent sepsis
VS q15 min until stable Check dressing & perineal pad for bleeding, lochia
Danger Signs Thrombophlebitis: Local redness (rubor) Warm to touch (calor) Swelling (tumor) Pain (dolor)
Regular positioning
Early exercise
Passive then active leg exercises (Foot & leg exercise, abdominal tightening, pelvic rocking)
Effects of Anesthesia
Trauma to nerve root or spinal cord (paresthesia) Postdural puncture headache (flat on bed)
maneuver
Partograph
Birthing Centers
Maternity facilities Hospital or institution close to a hospital Warm, homelike environment
Families take more responsibility for birth experience NOT for high-risk deliveries Care provided by nurse-midwives
Home births
-
Inadequate medical back-up Woman must ensure the home is prepared for birth must be in good health 6 Cleans (WHO) Clean hands Clean delivery surface Clean tie for the cord Clean blade Clean cloth for mother Clean cloth for baby
Water birth
sitting or reclining in warm water bath NB is born under water and brought out of the water for the first breath
Relaxation occurs due to warm water Risk of fecal contamination May lead to uterine infection & neonatal aspiration of water