OB:(Intrapartum Assessment and Interventions)

What is fetal attitude?

Posturing of the joints and the relationship of the fetal body parts (chest, chin, arms) to each other. Flexion- NORMAL fetal attitude when labor begins Extension increases diameters

What is the fetal lie?

The relationship of the fetal long axis to the long axis of the mother?

What are the levels of the station?

0 station = level of the ischial spines. -1 = 1 cm above the ischial spines +1 = 1 cm below the ischial spines etc.

What are lacerations and what are the degrees?

A tear in the perinum that may occur at delivery. First, second, third, and fourth.

What are the theories of labor? (Maternal factors for labor triggers)

1. Uterine stretch theory - stretched to capacity 2. Pressure on cervix --> oxytocin from pituitary 3. >Estrogen --> irritable uterus 4. Progesterone deprivation --> < quieting 5. >Oxytocin & Prostaglandin --> >intracellular calcium --> contractions

Dilation occurs because of what?

1st: contractions > diameter of the cervical canal lumen by pulling the cervix up over the presenting part. 2nd: the fluid filled membranes press against the cervix.

Low-lying placenta can cause baby to assume what position?

A transverse lie.

What are the factors affecting labor?

5 Ps Powers (the contractions) Passage (the pelvis) Passenger (the fetus) Psyche (the response of woman) Position (maternal postures and physical positions to facilitate labor.

What is station?

The relationship of the presenting part of the fetus to an imaginary line drawn between the ischial spines of the maternal pelvis.

What are the characteristics of the active phase?

Average dilation 1.2 cm/hr depending on gravida Dilation progresses 4-7 cm, 40-80% effacement Increase contractions 2-5 mins, lasting 40-60 seconds. Increase in pain Rupture membrane Evaluate fetal status Internal monitoring Pain assessment Evaluation progression in labor. Monitor 2hrs; 1 hr if ROM. Monitor FHR 15-30 mins.

What is the fetal position?

The relationship of the presenting part to the specific area of the woman's pelvis.

What are the characteristics of the fourth stage of labor?

Begins the PP Ends 4 hours after delivery Mechanisms of homeostasis occurs. Repair episiotomy or laceration Inspect placenta Assess the fundus for firmness. Order uterotonics Order pain meds, if nec. Explain all procedures Assess uterus for position, tone, and location, intervening with fundal massage as nec. Assess lochia for color, amount, and clots. Admin. meds. Assess maternal vital signs every 15 mins. Monitor perineum for unusual swelling or hematoma formation. Apply ice packs Monitor for bladder distention. (assist woman to the bathroom and measure void) Assess for return of full motor-sensory function if epidural or spinal anesthesia used. Stay with mother and family. Offer congratulations and job well done. Monitor newborn's status Q 30 min.

Which measurement is the largest transverse measurement and an important indicator of head size?

Biparietal diameter (BPD)

Placenta previa can be associated with what presentation?

Breech

What are the three main presentations?

Cephalic (head first [vertex, brow, face]) Shoulder Breech (pelvis first [complete, frank {just foot/feet to face}, footling])

What are characteristics of the latent phase?

Cervix 0-3 cm dilation 0-40% effacement Contraction every 5-10 min, mild intensity, lasting 30-45 seconds. Discomfort described as feelings of strong menstrual cramps Order labs Order IV or saline lock Continuous fetal monitoring Admit to labor unit and orient woman. Group B

How do you know which surface of the placenta is the fetal surface?

The shiny side. Covered by amnion.

What are the characteristics of the transition phase?

Dilation from 8-10 cm, 100% effacement Contractions intense, 1-2 min lasting 40-60 seconds. Bloody show Strong urge to bear down, losing control. Perform amniotomy (AROM) if not done Assess fetal position and cervix. Prepare for delivery. Assess FHR and UC Q 15 mins. Support Encourage woman to breathe

What are pushing techniques?

Directed pushing -BEGINS when mother is COMPLETELY dilated -Patient takes one good breath, then takes and holds a second -While holding the breath, she pulls back her knees, bears down and pushes for a count of 10 -Cycle of inhale, hold, push repeated X2 during a single contraction.

What is external rotation (restitution)?

During this movement, the sagittal suture moves to a transverse diameter and the shoulders align in the anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis.

What is expulsion?

The shoulders and remainder of the body are delivered.

What is engagement?

Engagement occurs when the biparietal diameter is at or below the inlet of the true pelvis.

What are the mechanisms of labor?

Engagement, descent, and flexion Internal rotation Extension External rotation Expulsion

What is engagement, descent, and flexion?

Engagement: When the greatest diameter of the fetal head passes through pelvic inlet; can occur late in pregnancy or early in labor. Descent: Movement of the fetus through the birth canal during the first and second stages of labor. Flexion: When chin of fetus moves toward the fetal chest; occurs when the descending head meets resistance from maternal tissues. Smallest fetal diameter to maternal pelvic dimensions.

What is a fourth-degree laceration?

Extends into the rectal mucosa and exposes the lumen of the rectum.

What are fontanelles?

The space where two sutures meet. -Covered by a membrane.

What is extension (rotation complete)?

Facilitated by resistance of the pelvic floor that causes the presenting part to pivot beneath the pubic symphysis and the head to be delivered; second stage.

Leopold's maneuvers are 4 maneuvers which provide information on what?

Fetal lie Presentation Position Engagement Abdominal palpation also shows degree of: uterine irritability, tone, tenderness, current contractility, and fetal movement.

Position is designated by a three-letter abbreviation. What do they stand for?

First letter: designated location of presenting part to L(left) or R(right) Second letter: designates specific fetal part presenting: occiput (O), sacrum (S), mentum (M), and shoulder (A). Third letter: Designates relationship of the presenting fetal part tot he woman's pelvis such as anterior (A), posterior (P), or transverse (T).

What are problematic presentations?

Frank Incomplete Left sacral anterior Left sacral posterior Brow Prolapse of Cord

Contractions are described how?

Frequency: beginning of one to the beginning of another Duration: from beginning to end of one Intensity: Strength of the contraction. -Mild: uterine wall is easily indented during contraction. -Moderate: The uterine wall is resistant to indentation during a contraction. -Strong: the uterine wall cannot be indented during a contraction. Nose-->chin-->forehead

What are the four types of pelvis?

Gynecoid (most common) = ideal wide sacrum, flat iliac bone, >basin Android Anthropoid = "ape like" long A-P, <transverse diameter Platypelloid (least common)

What is the procedure for external version?

IV Ultrasound Terbutaline (to relax uterus) Rhogam (if Rh- negative) Provide for emergency C-S RISK: separation of the placenta, uterine rupture, fetal-maternal hemorrhage, failure. Very painful for mother.

When ROM/BOW occurs, what do you do?

Immediately assess FHT.

What are premonitory signs of labor?

Impending labor. A few weeks before labor, changes occur that indicate the woman's body is preparing for the onset of labor.

What are the three phases of a contraction?

Increment phase: ascending or building of contraction. Begins in fundus and spreads throughout fundus. LONGEST PART Acme phase: peak of intensity SHORTEST. Decrement phase: descending or relaxation of uterine muscle.

What is a first-degree laceration?

Involves perineal skin and vaginal mucous membrane

What is a second-degree laceration?

Involves skin, mucous membrane, and fascia of the perineal body.

What is a third-degree laceration?

Involves skin, mucous membrane, and muscle of the perineal body and extends to the rectal sphincter.

What are the signs of impending labor?

Lightening Braxton-Hicks contractions: IRREGULAR UCs. Do not result in cervical change and are associated with false labor. Cervical changes: cervix becomes soft (ripens) and becomes partially effaced and begin to dilate. (Goodell's sign) Surge in energy (*nesting*) > epinephrine GI changes (diarrhea, nausea, digestion) Backache (relaxation of pelvic joints) Bloody show: brownish or blood-tinged cervical mucus

What are the pushing positions?

Lithotomy: physician-attended births. Lateral: *can help rotate a fetus that is in posterior position* Can slow a precipitous birth Allows the perineum to stretch gradually. Alternative positions: hands and knees, standing or semi-supported squat Squatting: the natural position for pushing.

What are issues with occiput posterior "sunny side up"?

Longer labors Spontaneous or assisted rotation to OA. Some feel that sedentary behavior in Mom increase this.

What are the characteristics of the third stage of labor?

Period involving separation and expulsion of placenta/membranes Lasts 5-20 minutes At delivery, neonate is placed skin-to-skin on mother's abdomen Await delivery of placenta Inspect placenta after delivery Order pain meds and uterotonics if necessary Assess maternal vital signs Q 15 mins. Encourage to breath with contractions and relax between contractions. Complete documentation.

What are fetal factors for labor triggers?

Placenta aging --> initiation of contractions Prostaglandin synthesis by fetal membranes and decidua --> contractions Fetal cortisol increases --> acts on placenta to reduce progesterone that quiets uterus --> increase prostaglandins --> contractions

What are the two types of contractions?

Primary (involuntary) Secondary (voluntary) - maternal bearing-down efforts.

What is doula?

Relieve male partner of need to push the pregnant woman.

What is effacement?

Shortening and thinning of the cervix.

What are the stages of labor?

Stage 1: Begins with onset of labor and ends with complete cervical dilation. (Latent phase [no showing, backache], Active phase [restless, labored respiration, fear, anxiety, show increasing]. Transition phase [leg cramps, nausea, perspiration, pain, heavy showing]) Stage 2: Begins with complete cervical dilation and ends with delivery of baby Stage 3: Begins after delivery of baby and ends with delivery of placenta Stage 4: Begins after delivery of placenta and is completed 4 hours later.

What are the characteristics of the second stage?

Sudden burst of energy, improved focus. Complete dilation and effaced. Frequency 1-2 mins Duration 60-90 seconds. Intense Bulging rectum and vagina, perineum flattens. Shorter with multips than primips. Prepare for delivery Provide reassurance Perform episiotomy Assist woman in the birthing of her child. Instruct woman to bear down with urge to push. Check FHR every 5-15 mins after each contraction. Encourage rest between contractions.

What is fetal presentation?

The leading or most dependent portion of the fetus. Determined by part or pole of the fetus that first enters pelvic inlet.

What are sutures?

The meetings of the bones of the fetal skull. -Covered by a membrane

What is labor?

The process in which the fetus, placenta, and membranes are expelled spontaneously.

What is lightening?

To the descent of the fetus into the true pelvis that occurs approx 2 weeks before term in first-time pregnancies. - >frequency of voiding - > vaginal discharge - >Lordosis (inward curve of the lumbar spine) - *>Varicosities* - < breathing problems - Shooting pains down legs --> pressure sciatic

What do you for cord prolapse?

Trendelenburg position and list presenting part off cord Only 5 minutes of cord compression can lead to CNS damage or death.

What can you do for external cephalic version?

Turning the fetus to head first. Requirements: -Normal fetus with reassuring FHR tracing - Adequate amniotic fluid - Not in labor - Presenting part not engaged *Default option: cesarean delivery*

What are behaviors in second stage?

Urge to bear down is strong Pushing feels more productive; eager to push Exhausted mothers may find exertion overwhelming Burning as head crowns often causes fear of "splitting open" Pushing causes very intense sensations that can frighten unprepared mothers.

Each contraction has a resting phase. What is the resting phase?

Uterine relaxation period that allows the woman and uterine muscles a pause for rest. Allows blood to flow to the uterus and placenta. Contraction = 500 mL of blood leaves the utero-placental unit and moves back into maternal circulation.

The passageway consists of soft tissue, which consists of?

Uterus Cervix: Cervical scarring (LEEP, conization, biopsy) Prolonged effacement period followed by rapid dilation once tissue softens Pelvic floor Vagina: tissue dystocia (difficult birth) Introitus

The placenta can impede the descent of what presentation baby?

Vertex

What are the different types of fetal lie?

Vertical/longitudinal (normal, common) - Head first Vertical/longitudinal (variation) -Breech (complete, frank, single footling) Perpendicular/transverse (abnormal/oblique)

What is internal rotation?

When the rotation of the fetal head aligns the long axis of the fetal head with the long axis of the maternal pelvis; occurs mainly during second stage of labor.

What is dilation?

Widening of the cervical extend os from less than 1 cm, to full dilation (approx. 10 cm) to allow birth of a full term fetus.