Maternity exam 3 study guide- The labor process

Right occiput posterior (ROP)

occupit to the right side of moms pelvis and also towards posterior surface of her pelvis. If the fetus is in an occiput posterior position, the fetal head must rotate 90 degrees rather than 45 degrees. The typical result is a prolonged and painful "back" labor.

Psyche of labor

pg. 161 box 8-2 Factors that may affect the maternal psyche: Current pregnancy experience, previous birth experiences, expectations for current birth experience, preparation for birth, presence and support of a birth companion, a woman's culture influences, pain, relationships, the childbirth experience, and the significance of touch.

Epidural*

*how is it done? Risks to look for/complications. Recovery phase-what to expect with epidural. May have urinary retention because of the numbness of the epidural. This method provides excellent pain relief, often completely blocking pain sensation. A small catheter is placed into the epidural space and then injects the catheter with local anesthetics or opioids to provide labor pain relief. Read pages 180-182. possible side effects: hypotension, tinnitus, puritis, nausea and vomiting, respiratory pressure, fever, and fetal bradycardia.

Types of pain management techniques

*Know at what point do they generally administer those.

EFM patterns

*Mostly patterns of reassuring or non-reassuring. We want variability in the heart rate.

VBAC

*why wouldnt you allow someone to have a VBAC? vaginal birth after cesarean section. -Contradictions: The risk for uterine rupture during VBAC is much higher when a woman has a classical uterine incision from a pervious cesarean delivery; therefore, VBAC is contraindicated when this type of scar is present. Other contraindicated include any complication that disqualifies the woman for a vaginal delivery such as placenta previa, history of previous uterine rupture, and lack of facilities or equipment to perform an immediate emergency cesarean.

Pudendal block

*178- know what it will and will not do. Does not compare to an epidural. Will not help the pain of labor because it only numbs the vaginal walls. A pudendal block is given just before the baby is born to provide pain relief for the birth. The physician injects a local anesthetic bilaterally into the vaginal wall to block pain sensations to the pudendal nerve. A pudendal block can be helpful for instrument-assisted deliveries and for repair of an episiotomy or perineal tear. If an incomplete block occurs, the health care provider may have to inject additional local anesthesia for episiotomy repair. This method IS NOT effective to relieve the pain of labor.

Fetal presentations*

Fetal presentation refers to the foremost part of the fetus that enters the pelvic inlet. There are three main ways that the fetus can present to the pelvis: head (cephalic presentation), feet or buttocks (breech presentation), or shoulder (shoulder presentation). A cephalic presentation is the most common presentation.

Fetal positions abbreviations (pg. 159 box 8-1)

First designation: Refers to the side of a maternal pelvis in which the presenting part is found. - Right (R) -Left (L) Second (middle) designation: reference point on the presenting part -Occiput (O)-vertex and military presentations -Frontum or brow (Fr)-brow presentation - Mentum or chin (M)-face presentation -Sacrum (S)-breech presentation -Scapula (sc)-shoulder presentation Third (last) designation: Refers to the front, back, or side of the maternal pelvis in which the reference point is found -Anterior (A)-front of pelvis -Posterior (P)-back of pelvis -Transverse (T)- side of the pelvis

Uteroplacental insufficiency

Late decelerations are associated with uteroplacental insufficiency, diminished or deficient blood flow to the uterus and placenta. This pattern occurs from chronic interruption of the blood supply to the placenta. This is a grave situation because the placenta is the fetus's sole source of oxygen. Interventions are aimed at improvising blood flow to the placenta. Some maternal conditions, such as hypoxemia, decreased cardiac output or hypotension, can also affect the oxygen supply to the fetus. Notify the RN or the birth attendant of any late decelerations.

Stages of labor: fourth stage

The fourth stage is the recovery stage. Because of the tremendous changes that the new mothers body goes through during the process of labor and delivery, the period of recovery after delivery of the placenta is considered to be a fourth stage of labor. This recovery may last from 1 to 4 hours. During this fourth stage, observe the woman frequently for signs of hemorrhage or other complications.

At what stage of labor does the nurse generally give narcotics?

The transitional phase

Left occiput transverse (LOT)

occupit is leaning against ischial spine , toward the left

Pelvic shape: Platypelloid pelvis

This is the least common type of pelvis shape. This pelvis is flat in it's dimensions with a very narrow anterior-posterior diameter and a wide transverse diameter. This shape makes it extremely difficult for the fetus to pass through the bony pelvis. Therefore, women with platypelloid pelvises must usually deliver the fetus by cesarean section.

Pelvic shape: Gynecoid pelvis*

This is the most favorable for a vaginal birth. The rounded shape of the gynecoid inlet allows the fetus room to pass through the dimensions of the bony passageway. This is considered the typical female pelvis, although only about half of all women have a gynecoid pelvis.

Fetal position

* has a lot to do with the presenting part. The health care provider will determine fetal position by first establishing the presenting part (occiput, brow, etc). The provider then determines if the part is facing the maternal right or left side and also which direction it is facing in relation to the maternal pelvis. Then, they see if the baby is facing the anterior, posterior, or transverse position. Fetal positions is documented in the clinical record using abbreviations. (A transverse position is not the same as a transverse lie. Transverse lie refers to the way the fetus body is aligned in the uterus whereas transverse position refers to the way the presenting part is aligned to the maternal pelvis.)

Bishop score

*234, medications for cervical ripening. a scoring system to determine whether labor can be safely induced. A cervix that is favorable for induction is called a "ripe" cervix. Five factors are evaluated in the Bishop score: cervical consistency, position, dilation, effacement, and fetal station. The higher the score, the greater the chance that induction will be successful. A Bishop score of 6 or less indicates an unripe, or unfavorable cervix, and labor induction is less likely to be successful. Score: (0 )Dilatation: )closed) Effacement (%): 0-30% Station: (-3) Cervix: (Firm) Cervical position: (Posterior) Score: (1) Dilatation: (1-2cm) Effacement (%): 40-50% Station: (-2) Cervix: (Medium) Cervical position: (Midposition) Score: (2) Dilatation: (3-4cm) Effacement (%): 60-70% Station: (-1) Cervix: (soft) Cervical position: (Anterior) Score: (3) Dilatation: ( greater or equal to 5cm) Effacement (%): ( greater or equal to 80%) Station: (greater than or equal to +1)

Pros and Cons of pain medications

*Cons- Most all of them cross the placenta. Pro- maternal fatigue is an issue, and excessive pain will wear the mother out.

Safety during labor

*If the membranes have already ruptured, we will not let the ambulating mother ambulate alone. Safety as related to an epidural-after delivery. Will not let the postpartum mother even attempt to stand until sensation is back in the lower limbs.

Assessment of labor

*Think about the stress it puts on the maternal body. Breathing, cardiac, what does the maternal body go through overall? First- check for imminence and well being of mother/baby Immediate assessments: -Birth imminence*: This begins from the moment the woman arrives in the labor and delivery unit. If the woman is introverted and stops to breathe or pant with each contraction, you can infer that she is in an advanced stage of labor. -Fetal status: The woman is placed on the fetal monitor for continuous monitoring, but it is within accepted standards of care to check the fetal heart rate by fetoscope or by doppler. The FHR should be strong and regular, with a baseline between 110 and 160bpm. -Risk assessment:

Mechanisms of a spontaneous vaginal delivery

*This is a cascade that has to happen For a vaginal birth to occur, the fetus (passenger) must pass through the birth canal (passageway). The turns and movements made during birth are referred to as the cardinal movements (or mechanisms) of delivery. These seven movements are engaged, descent, flexion, internal rotation, extension, external rotation, and expulsion. Although the movements are discussed separately, it is important to understand that they may overlap of occur simultaneously.

Cardinal movements of delivery

-Engagement: Initial descent of the fetal head results in engagement when the presenting part descends to the level of the ischial spines. Engagement may occur as early as 2 weeks before labor or not until after the onset of labor. Engagement is more likely to occur earlier in the primigravida and later in the multigravida. -Descent: Descent may begin before labor when the fetus "drops". Descent is measured by station, which is the relationship of the fetal-presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches a fetal station of plus four. -Flexion. As the head descends during labor, the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. This resistance normally coaxes the fetus to assume an attitude of flexion. Flexion is the attitude that presents the smallest diameters of the fetal head to the dimensions of the pelvis. -Internal rotation: Frequently, in an early labor, the fetal head presents to the pelvis in a transverse position because the inlet of the pelvis is widest from side to side. During active labor, the fetal head typically rotates 45 degrees from a transverse position to an anterior position so that the head can accommodate the pelvic outlet, which is wider from front to back. If the fetus does not rotate, the widest diameters of the fetal head present to the outlet of the pelvis, resulting in a less than optimal fit between the head and the bony passageway. This can prolong labor. -Extension: Typically, the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. When the fetus reaches the pubic arch, it must extend under the symphysis pubis. -External rotation: As the head is born, external rotation lines the head up with the shoulders. -Expulsion: Expulsion (birth) occurs after the delivery of the anterior and posterior shoulders.

Fetal station

0 is engaged* Station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. When the widest diameter of the presenting part is at the level of the ischial spine, the station is zero (0). If the presenting part is above the level of the ischial spines, the station is recorded as a negative number and is read "minus". If the presenting part is below the level of the ischial spines, the station is recorded as a positive number and is read "plus". For example, in a cephalic presentation, if the widest part of the fetal head is 1 cm above the level of the ischial spines, the station is reported as a minus one and recorded as "-1". If, on the other hand, the presenting part is 1 cm below the level of the ischial spines, the station is reported as a plus one and recorded as "+1". When the station is a -4 or higher, the fetus is said to be floating and unengaged. When the fetus is floating, the presenting part has not yet entered the true pelvis. When the presenting part has settled into the true pelvis at the level of the ischial spines, the fetus is said to be engaged and is reported to be at a station of 0.

Pelvic shape: Android pelvis

This is the typical male pelvis and resembles a heart in its shape. Approximately one third of white women and 16% of non-white women have an android pelvis. Large babies often become stuck in the birth canal and must be delivered by cesarean, whereas a smaller baby may be able to navigate the narrow diameters.

How does the cervix soften/change during labor?

As the time for delivery approaches, the cervix usually begins to soften. Then, when labor begins, uterine contractions change the cervix in two ways. First, the cervix begins to get shorter and thinner, a process called effacement. Cervical effacement is recorded as a percentage. At a length of 1cm, the cervix is 50% effaced. The second cervical change that occurs during normal labor is dilation. the cervix must open to 10cm to allow the fetus to go through the birth canal. Normally, a primiparous woman experiences effacement before dilation. For a multiparous woman, both processes usually occur at the same time.

Left occiput anterior (LOA)*

babies back is facing left and forward, put monitor on left lower quadrant

Breech presentations

Breech presentations occur in approximately 3% of term pregnancies. Shoulder presentations are the least common, occurring in less than 0.3% of all term pregnancies. Shoulder presentation is associated with a transverse lie.

True labor Vs. False labor

Cervical changes- true: Progressive dilation and effacement. False- No change Membranes- True: May bulge or rupture spontaneously. False: Remain intact Bloody show-True: Present False: Absent; may have pinkish mucus or may expel mucus plug Contraction pattern- True: Regular (may be irregular at first) pattern develops in which contractions become increasingly intense and more frequent. False: Pattern tends to be irregular; although the contractions may seem to have a regular pattern for a time. Pain characteristics- True: Often starts in the small of the back and radiates to the lower abdomen; may begin with a cramping sensation. False: May be described as a tightening sensation; usually the discomfort is confined to the abdomen. Effects of walking- True: Contractions continue and become stronger. False: May decrease the frequency or eliminate the contractions altogether. *False labor: you can change something and make it go away (position, hydration, etc) True labor: will not stop- it will continue

Right Occiput Transverse (ROT)

baby's occupit to the right side of moms pelvis, baby is transverse, occiput is against ischial spine

Right occiput anterior (ROA)*

babys occiput it to the right side of moms pelvis but also toward the anterior surface of the pelvis

Leopold Maneuvers

Leopold maneuvers are a noninvasive method of assessing fetal presentation, position, and attitude. This technique can also be used to locate the fetal back before applying the fetal monitor. All you need for this procedure is warm, clean hands. -1: Determine presentation: stand beside the woman, facing her. Place both hands on the uterine fundus and palpate the fundus. If the buttocks are in the fundus (indicating a vertex presentation), you will feel a soft, irregular object that does not move easily. However, if the head is in the fundus indicating a breech presentation, you will palpate a smooth, hard, round, mobile object. -2: Determine position. Place both hands on the maternal abdomen, one on each side. Try to determine the location of the fetal back and extremities in relationship to the maternal pelvis. The back will feel hard and smooth, and the extremities will be irregular and knobby. -3: Confirm presentation. Place one hand over the symphysis pubis and attempt to grasp the part that is presenting to the pelvis between your thumb and fingers of one hand. Normally you will feel a hard, round, fetal head. IF the part moves easily, it is unengaged. -4: Determine attitude. Begin the last step by turning to face the woman's feet, and palpate downward in the direction of the symphysis pubis. If there is a hard, bony prominence on the side opposite the fetal back, you have located the fetal brow, and the fetus is in an attitude of flexion.

Non-pharmacologic Vs. Pharmacologic pain interventions

Non-pharmacologic: -Continuous labor support: This is a trained nurse or doula to give support throughout the L/D. - Comfort measures: Lip balm, ice chips, lollipops, and clear liquids can help moisten the mouth from excessive mouth breathing. Changing bed linens. -Relaxation techniques: When the woman becomes anxious, she tenses her muscles. This action can slow the labor process and decrease the amount of oxygen reaching the uterus and the fetus. when the woman maintains a state or relaxation during and between contractions, she is actually working with her body to facilitate the labor process. Some relaxation techniques include: Patterned breathing, attention focusing, movement and positioning, touch and massage, hydrotherapy, imagery, hypnosis, intradermal water injections, acupressure and acupuncture, slow-paced breathing, modified-paced breathing, and patterned paced breathing. pg. 174 table 9-1 has chart of each. Pharmacologic: The ideal pharmacologic method is to provide excellent pain relief and still allow the woman to freely change positions, ambulate, and not impair the woman's cognitive state. -Look on page 179 for table comparing pharmacologic interventions for relief of labor pain.

Pelvic shape: anthropoid pelvis

This is elongated in its dimensions. The anterior-posterior diameter is roomy, but the transverse diameter is narrow compared with that of the gynecoid pelvis. However, a vaginal birth can often be accomplished in approximately one third of women who have variations of an anthropoid pelvis.

Stages of labor: Second stage

The second stage is the birth. This stage begins when the cervix is dilated fully to 10cm and ends with the birth of the infant. Contractions usually continue as a frequency of every 2 to 3 minutes, last 60 to 90 seconds, and are of strong intensity. The average length of the second stage is 1 hour for primiparas and 20 minutes for multiparas, although it is normal for a primipara to be in this stage for 2 hours or longer. The woman is encouraged to use her abdominal muscles to bear down during contractions while the fetus continues to descend and rotate to the anterior position. Fetal descent is usually slow but steady for the primipara, from the active phase of the first stage though the second stage.

Pelvic shape

The shape of the inlet determines the pelvic type. There are four basic pelvic shapes: gynecoid, anthropoid, android, and platypelloid. Most women have pelvises that are various combinations of the four types. The most important measurement of the pelvic inlet is the obstetric conjugate, because this is the smallest diameter through which the fetus must pass. It is a measurement that takes into account the diagonal conjugate, which is the distance from the symphysis pubis to the sacral promontory. However, the obstetric conjugate cannot be measured directly; therefore, the health care provider must estimate the size. An obstetric conjugate that measures 11 cm is considered adequate to accommodate a vaginal delivery.

Stages of labor: third stage

The third stage is the delivery of the placenta. This begins with the birth of the baby and ends with the delivery of the placenta. This stage normally lasts from 5 to 20 minutes for both primiparas and multiparas. Signs that indicate the placenta is separating from the uterine wall include a gush of blood, lengthening of the umbilical cord, and a globular shape to the fundus. The placenta usually delivers spontaneously by one of two mechanisms. Expulsion by Schultze mechanism means that the fetal or shiny side of the placenta delivers first. Delivery by Duncan mechanism specifies that the maternal or tough side of the placenta is delivered first.

Four P's

There are four essential components of labor. These are known as the "four P's" of labor: passageway, passenger, powers, and psyche. A problem in any of these four areas will negatively influence the labor process. Passageway: The passageway consists of the woman's bony pelvis and soft tissues of the cervix and vagina. Passenger: The passenger refers to the fetus. The size of the fetal skull and the way the fetus is situated (which includes fetal lie, presentation, attitude, position, and station) can significantly affect labor progress. Powers: The primary force of labor comes from involuntary muscular contractions of the uterus. These labor contractions cause effacement and dilation of the cervix during the first stage of labor. Secondary powers are voluntary muscle contractions of the maternal abdomen during the second stage of labor that help expel the fetus. Psyche: Many factors affect the psychological state or psyche of the laboring woman. When the woman feels confident in her ability to cope and finds ways to work with the contractions, the labor process is enhanced. However, if the laboring woman becomes fearful or has intense pain, she may become tense and fight the contractions. This situation often becomes a cycle of fear, tension, and pain that interferes with the progress of labor.

Factors influencing labor pain

There are two general concepts related to pain that are helpful to understand: Threshold and tolerance. the pain threshold is the level of pain necessary for an individual to perceive pain. Pain tolerance refers to the ability of an individual to withstand pain once it is recognized. Each woman has her own threshold and tolerance of pain. Psychological influences for labor/delivery include fear, anxiety, culture, and the circumstances surrounding the pregnancy. Psychological factors can also influence the woman's perception of her pain. For example, the younger the woman is, the more likely the woman is to report extreme pain. When labor contractions are induced with oxytocin, women report them as extremely strong, intense, and lacking the gradual ebb and flow of naturally occurring contractions.

Nitrazine paper

To check to see if the membranes have ruptured, the RN may place Nitrazine paper in the fluid to determine the pH. If the membranes have ruptured and amniotic fluid is present, the Nitrazine paper will turn dark blue, indicating that the fluid is alkaline; this is a positive Nitrazine test. Symptoms indicating that the membranes have ruptured include reports by the woman of a gush or continual leaking of warm fluid from the vagina. Sometimes the woman will report intermittent leaking of fluid, and it may be unclear if the membranes have ruptured. Then, you would use a Nitrazine test to make sure

Rhogam

Used to prevent an immune response to Rh positive blood in people with an Rh negative blood type

Misoprostol Cytotec)

Using oral misoprostol to induce labour is effective at achieving vaginal birth. It is more effective than placebo, as effective as vaginal misoprostol and vaginal dinoprostone, and results in fewer caesarean sections than using oxytocin alone.

Left occiput posterior (LOP)

occiput is toward the left side of moms pelvis but lies toward posterior surface of her pelvis. If the fetus is in an occiput posterior position, the fetal head must rotate 90 degrees rather than 45 degrees. The typical result is a prolonged and painful "back" labor.

Stages of labor: first stage

pg. 165 table 8-3* (characteristics and maternal response are important- associated with the different stages and phases with change in psyche-possible change in stage and phase of labor, because they do not want to do vaginal exams due to increased risk of infection) what are indications for labor? First stage: Dilation. The first stage of labor begins with the onset of true labor and ends with full dilation of the cervix at 10 cm. This stage is subdivided into three phases: latent, active, and transition. -Early labor (latent phase): Early labor begins when the contractions of true labor start and ends when the cervix is dilated at 4 cm. Contractions during the phase are of mild intensity and typically occur at a frequency of 5 to 10 minutes, with a duration of 30 to 45 seconds. This phase lasts on average approximately to 8 to 9 hours for a primiparous woman but generally does not exceed 20 hours in length. Multiparous women usually experience shorter labors ( an average length of approximately 5 hours, with an upper limit of 14 hours) -Active labor (Active phase): The active phase begins at 4cm cervical dilation and ends when the cervix is dilatated at 8cm. Contractions typically occur every 2 to 5 minutes, last 45 to 60 seconds, and are of moderate to strong intensity. Progressive cervical dilation and fetal descent normally occur in this phase. Transition phase: Transition phase is the most difficult part of labor. This phase of the first stage of labor starts when the cervix is dilated at 8 cm and ends with full cervical dilation. The contractions are of strong intensity, occur every 2 to 3 minutes, and are of 60 to 90 seconds in duration. The woman often feels "out of control" as the contractions are frequent, longer than before, and intense in quality. This is usually the shortest phase of the first stage of labor. Frequently, the woman feels strong urge to push as the fetus descends. It is important for the woman to resist the urge to push until the cervix is dilated completely. Pushing against a partially dilated cervix can cause swelling, which slows labor, or the cervix can develop lacerations, leading to hemorrhage.

Episiotomy

surgical incision of the perineum to enlarge the vagina and to facilitate delivery during childbirth

Transverse lie

the baby lies crosswise in the uterus-shoulder tries to come out first.