Week 6 (Ch. 16, 19)

Relating to the "Psyche" P (5 P's of labor,) What is the pain --> fear --> tension cycle?

1960's (Dr. Dick-Read) proposed a model of pain expression called the fear-tension-pain cycle. No matter where one enters the cycle, each element can trigger the next in a downward spiral that magnifies the negative qualities of each. We want to BREAK this fear cycle for the patient. For example, if a woman enters labor fearfully, her muscles will tense...this tension reduces blood flow and the subsequent tissue ischemia results in a nociceptive or painful stimulus. The pain triggers more fear, which triggers more tension, and so on. Breaking the cycle of fear-tension- pain can happen at any level and is needed to prevent suffering, a central nursing objective. Note that pain and suffering are not necessarily the same. With a better understanding of the differences between pain and suffering, we would not imagine that the goal of care for a laboring woman is to avoid all discomfort or pain. If we suggest that the goal of labor support is to aid birth and to avoid suffering, we open the opportunity to view this healthy, physiologic process in a very different way than is typical in the US today. The alternative outcome of reduced fear is the confidence-relaxation-comfort cycle, which proposes more progressive, effective labor progress through conscious preparation for and management of physical and emotional perceptions. -The woman becomes relaxed, comfortable, confident --> decrease in oxygen utilization --> decreased fatigue (endorphins,) --> Increased oxygen to uterus --> Uterus contracts (oxytocin) --> Cervix dilates --> Decreased pain perception (the cycle keeps going in a circle)

What do we collect during the assessment portion of a woman in labor? Prenatal, interview, and physical assessment

Assessment begins at the first contact with the woman, whether by phone or in person; Assessment is always top priority. The nurse begins assessment by using techniques of interview and physical assessment and reviews the lab and diagnostic tests. Family, partner, or support system can also be included in the assessment. o Prenatal data: We should take note of the woman's obstetric history; gravidity, parity, and problems such as hx of vaginal bleeding, gestational hypertension, anemia, diabetes, infections, immunodeficiency status. o Interview: The woman's primary reason for coming to the hospital is determined during the interview. During triage, the nurse needs to determine the status of the woman's amniotic membranes o Assessing the woman's respiratory status is important in case general anesthesia is needed in an emergency. o Physical assessment: includes general systems and assessment of fetal status. Findings during the initial assessment serve as a baseline for assessing the woman's progress in labor from that point on. (Check heart, lungs, skin, edema in face, hands, sacrum and legs, as well as VS.) (Encourage woman to lie on her side to prevent supine hypotension and decrease oxygen to fetus—fetal hypoxemia)

Intrauterine pressure during labor What is the baseline tonus? (resting uterus at full term) What measurements classify a contraction as mild, moderate or strong? What are Montevideo units? What equation? What range for MU's?

Baseline tonus: 5 - 25 mmHg (For resting uterus at full term) Contraction Intensity: -<40 mmHg - Mild -40-60 mmHg - Moderate ->60 mmHg - Strong Montevideo Units: #UC's/10 mins (UCs in 10 min period) X mean amplitude Desired MU's = 200 - 250 (For progressive labor) -3 contractions within 10 min that have a mean amplitude of 50 = (3 x 50) = 150 mmHg which would indicate the primary powers of the labor would need to be increased a little bit. -If the number is too high (over 250) that means the mother is contracting too hard and we might want to titrate down oxytocin or other meds if we are giving them. As a hollow muscle, which has been stretched to many times its pre pregnant size, the uterus during labor is working to expel its contents and return to its prepregnant dimensions. With each contraction, the muscle fibers shorten, and measurable contractile pressure can be quantified when using an intrauterine pressure catheter. For most women, quantification of uterine powers is not necessary, since progressive labor is established by progressive changes in cervical dilation and fetal descent. However, when we need to measure actual intrauterine pressure to determine if primary powers are adequate, we can insert a catheter into the uterus.. These are the pressures in mm Hg for contractions of various intensities. We can use a system of calculating Montevideo units to determine whether the primary powers are adequate to support progressive labor and birth. The standard measure for adequate primary powers is between 200 and 250 MU's. We can use this system to guide the titration of labor inducing medication or to make decisions about delivery method over time when adequate forces are demonstrated, but no cervical progress results.

What are some factors that affect the passage (birth canal) What do the terms bicornuate, myxomas, incompetent cervix mean?

Bony Pelvis Anatomy (pelvic type, congenital malformations, injury) Uterine Anatomy (bicornuate, myomas) Cervical Condition (scarring, stenosis, incompetence) Pelvic Floor muscular tone Soft Tissue Considerations (maternal weight, perineal tissue integrity and elasticity) Factors which influence the birth passage include the anatomy of the bony pelvis, the anatomy of the uterus, cervical conditions, the muscle tone of the pelvic floor, and soft tissue considerations related to the vaginal canal. Bicornuate: Uterus that is heart shaped. (rare but a malformation) Myomas: Noncancerous growths on the uterus (Benign hyperplastic lesions of uterine smooth muscle cells.) Incompetent cervix: May dilate silently (contributor to premature labor/birth)

Uterine contraction patterns Functional contractions vs Dysfunctional contractions Intensity ranges, duration (in seconds) for each? Difference between hypotonic and hypertonic dysfunctional contractions?

Functional Contractions: -*regular, moderate intensity (40-60 mm Hg), 40-60 seconds in duration --- associated with progressive cervical dilation and effacement (thinning of cervix)* -Functional contractions in labor are characterized by their regularity, intensity, duration, increasing frequency, and associated cervical change. Dysfunctional Contractions: -* Hypotonic - regular or irregular, weak (< 40 mm Hg), short (< 40 seconds) -* Hypertonic - regular or irregular, weak with elevated uterine resting tone or strong intensity with short duration --- painful with little cervical change** Because the contractions are not efficient (too short or not strong enough) Labor pattern dysfunction can occur when contractions are either hypo or hypertonic, and may reflect underlying conditions such as dehydration, maternal anxiety or exhaustion, or a problem with one or more of the other P's

Pelvic dimensions Planes and Diameters What are the narrowest portions of the maternal pelvis? False vs true pelvis? What does the subpubic arch determine?

Inlet - Obstetric conjugate diagonal conjugate Midpelvis - Interspinous diameter *Plane of Least Pelvic Dimensions Outlet - Intertuberous (biischial) diameter -Angle of pubic arch In terms of measurements, it is most important to remember 3 things: 1) that the interspinous and intertuberous diameters are the narrowest portions of the maternal pelvis 2) that these average measures are slightly larger than the largest measurement of an average-sized baby's head 3) measures of both the pelvis and the baby's head can vary due to the ability of the pelvis to expand and the head to compress. The bony pelvis is separated by the brim/inlet into two parts; The false (upper) and true (lower) pelvis -The false pelvis plays no role in childbearing. The true pelvis is divided into three places (inlet, brim/midpelvis, and outlet.) -The inlet is the inner portion, the midpelvis is the curved passageway, and the outlet is the lower portion of the true pelvis and is diamond shaped. In the latter part of pregnancy, the coccyx is moveable (unless previously fractured.) The subpubic angel (which determines the type of pubic arch) is important because the fetus must first pass beneath the pubic arch (a narrow subpubic angel is less accommodating than a rounded wide arch.)

What are the premonitory signs of labor onset?

Lightening (Baby dropping down as it begins to engage in the pelvis, causes a decrease in fundal height.) Decrease in work of breathing (baby is getting out of her diaphragm. Also see an increase in pelvic pressure) -In first time pregnancies, the uterus sinks downward and forward about 2 weeks before term. (also called dropping.) After lightening, there's less pressure against the rib cage and women can breathe more easily (bladder pressure comes back though.) Lightening may not take place in multiparous women until after/during true labor. Cervical Ripening (Cervix softens and thins, effacement) Energy Surge* (common premonitory sign) Vaginal discharge - mucous plug loss* has pink streaks -Vaginal mucous becomes more profuse, Brownish blood-tinged cervical mucous (mucous plug) may be passed (bloody show) Sleep disturbance (towards end of pregnancy) Low backache occurs and sacroiliac distress as a result of relaxation of the pelvic joints. Other: weight loss of 1-3.5lbs from electrolyte shifts and changes in progesterone (decrease) and estrogen. Sometimes diarrhea, nausea, vomiting, and indigestion occur. (burping as well)

Secondary powers Open glottis vs closed glottis pushing

Open-glottis pushing - instinctive and spontaneous; accompanied by some exhalation/vocalization during the bearing down effort (Mother releases a little bit of air during push instead of holding all the air in**) (this is what we want to encourage during birth) Closed-glottis pushing - usually provider directed; risk of increasing intrathoracic and cardiovascular pressure that can cause compromised placental perfusion (decreased O2 to the baby) and risk for perineal trauma (Holding breath, leads to more issues) Secondary powers, or voluntary maternal expulsive efforts, aid in the last 3 cardinal movements of labor, extension, external rotation, and expulsion. Factors which influence the mother's ability to push will affect the quality of the secondary powers.

Normal physiologic birth definition

Physiologic birth is a more specific term defined as a process powered by the innate human capacity of mother and baby. This refers to a birth that is spontaneously initiated (rather than chemically induced), and spontaneously concluded (vaginally, without assistance). This type of birth is associated with the lowest rates of morbidity and the most favorable outcomes for the low-risk, full-term, uncomplicated pregnancy.

Muscle and soft tissue How do muscles of the pelvic floor influence labor/birth? What part of the cervix is the examiner feeling for when doing their examination? How/why does cervical dilation happen during labor?

The uterus, cervix, muscles of the pelvic floor, vagina, and perineal tissues all play a role in helping or hindering the birth process. Birth is gradual, allowing the baby to move through the canal at a rate that is not traumatic to mother and fetus. The uterus contracts, pulling the tissues of the cervix upward as the baby is moving downward. The muscles of the pelvic floor provide the tone and structure to help mold and direct the baby through the rotational maneuvers. Examiner is feeling external os when doing their examination** (Cervix) The cervix in the non-laboring woman is 3-5 centimeters long with an interior opening and exterior opening called the internal os and the external os, respectively. During labor, the cervix softens, thins, or shortens, and dilates to open the aperture of the os. The uterine contractions and downward pressure of the baby's head, along with chemical changes at the time around labor onset, stimulated cervical dilation. A woman who has experienced prior cervical trauma or surgery, may have scarring on the cervix, which makes dilation more difficult.

Vertex presentation Sinciput presentation Brow presentation Cm's for each of these?

Vertex presentation: Complete flexion of the head (chin to chest) allows the smallest biparietal diameter for easy passage through the pelvis (9.5cm) (what we want) Sinciput presentation: moderate extension of the head (military attitude) makes a larger diameter entering the pelvis (bad) (12cm) -When the baby is in a military attitude (or sinciput presentation), the head is not flexed and you can see that there is a much larger diameter needed to be accommodated. (Neck is not tucked down but looks normal) Brow presentation: Marked extension (deflection) so that the largest diameter (too large to pass through pelvis) is presenting. (bad) (13.5 cm) -This is also called an attitude of extension, the baby's head is tilted backward with the chin up, and this is the largest diameter that could be presented into the pelvis. Also the most difficult to get through. The examiner will feel the baby's face in this presentation.

Station and descent What is dilation? What is effacement? What does station mean? How do we determine it? Birth is imminent when the presenting part is at what point?

We represent progress in labor by documenting cervical status as well as the level of descent of the fetal presenting part. 1) Dilation is expressed by the number of centimeters in diameter the cervical os is open and ranges from 0 to 10. 2) Effacement refers to how long the cervix is and is expressed in a percentage from 0 to 100, with 100%representing full effacement or a fully thinned out cervix. (the cervix is about 3cm thick) 3) Station: The degree of decent that the baby has made through the pelvis; Fetal descent is documented using the landmarks of the ischial spines (located in the midpelvis) and the top of the baby's head. -When the top of the baby's head is level with the ischial spines the baby is said to be a zero station* -The higher the baby is felt in the pelvis, the more negative the number, and the lower the baby is, the more positive the number. -We measure the station in cm above or below the ischial spines. 1cm above the spines is notes as "-1" At the level of the ischial spine = 0 When the presenting part is 1 cm below the spine = +1 Birth is imminent when the presenting part is +4/+5 cm Nurses perform cervical exams when necessary to determine progress in labor. This is a blind assessment, relying on the sense of touch and experience to determine dilation, effacement, and station. This baby is at zero station

LOP

left occiput posterior Occiput is posterior (facing towards back of mom) (will be born face up)

Factors that influence "Powers" (Secondary powers) -- Aka the mothers ability to push What are catecholamines? When are they released and how do they affect the mother/baby?

o Energy Substrate that the mother has before and during labor- fatigue, nutrition, hydration status (Moms who go into labor with good hydration and less fatigue have better outcomes) o Uterine contractility (Primary and secondary powers) o Use of medications for labor induction/augmentation (Oxytocin) o Maternal activity and positioning o Drugs - analgesia/anesthesia o Time (in relation to drugs and their duration) o Anxiety and Stress (Can cause catecholamine release which can inhibit uterine contractibility) o Secondary Powers - Maternal Pushing Efforts* To review, primary and secondary powers are necessary to complete the vaginal birth process. The quality of these powers is determined by the energy substrate women have going into and progressing through labor. This includes nutrition and hydration status, as well as rest and fatigue status. The use of exogenous agents to stimulate contractions and cervical change, such as prostaglandins and oxytocin, will enhance the primary powers, but must be used cautiously, because overstimulation of the uterus can result in fetal hypoxia, uterine muscle fatigue and, in the most extreme cases, uterine muscle rupture. Maternal activity and rest can promote uterine contractility as can various positions during labor. Various analgesic medications and regional anesthetics such as epidurals can inhibit both primary and secondary powers. Time, anxiety, and stress can have a fatiguing and inhibitory effect on the powers of labor. Women with extreme fear or anxiety can release catecholamines into their blood stream, which shunt blood flow away from the uterus and reduce functional contractility of the muscle fibers. (fight or flight response) Fear can also contribute to a mother's reluctance to push in the second stage of labor, and nurses may need to reassure their patients about the sensations they are having and that they are in a safe environment for birth.

What are some passenger considerations? (5 P's) What is placenta previa?

o Fetal presentation and position o Fetal malformations o Membrane status o Fetal tolerance of labor and birth To review: the passenger's contribution to progressive vaginal birth is influenced by the presentation and position of the baby, any fetal malformations which create a larger or smaller than expected diameter (such as hydrocephalus or microcephaly), and the status of the amniotic membranes. The amniotic sac provides a dilating wedge that is less efficient, but more comfortable at dilating the cervix. We should also note that the placenta is part of the passenger's luggage and needs to arrive after the passenger. In cases of placenta previa, where the placenta is presenting before the fetus, cesarean section is indicated. Throughout labor, the fetus is periodically assessed to determine how well he/she is tolerating the birth process. This is usually accomplished with auscultation or continuous monitoring of the fetal heart rate. If the fetus demonstrates any decompensatory signs during labor, it is an indication for intervention to improve oxygenation, or to accelerate the birth process

LOA

left occiput anterior Occiput is anterior (facing towards front of mom)

The nurse performs a vaginal examination and determines that the fetus is in a sacrum anterior position. The nurse draws which conclusion from this assessment data? A. The fetal sacrum is toward the maternal symphysis pubis. B. The fetal sacrum is toward the maternal sacrum. C. The fetal sacrum is in the maternal uterine fundus. D. The fetal face is toward the maternal symphysis pubis.

A

Baby born "on call" ?

Baby born "on call" = baby born with amniotic sac intact

The process of labor is enhanced when a woman does what during the first stage of labor?

Changes her position frequently

What are some maternal/anatomic and physiologic adaptations to labor? Cardiovascular system Respiratory changes Renal changes Integumentary system Musculoskeletal changes Neurological changes GI changes Endocrine changes -Do WBCs increase or decrease during labor? -Increase of decrease in RR? What does this cause? -What level of proteinuria is normal, why does this happen? -Endorphins released during labor cause the mother to have what? -Changes of GI tract? -Endocrine changes (progesterone and estrogen levels) -Glucose level changes during labor?

Cardiovascular system: during each contraction, 300-500ml blood is shunted from the uterus to the maternal vascular system -By the end of the first stage of labor, CO during contractions is increased by up to 51%** above baseline pregnancy values at term. (10-15% in first stage, 30-50% in second stage.) CO peaks about 10-30 minutes after both vaginal and C-section birth and returns to its prelabor baseline within the first hour. --A DROP in maternal heart rate accompanies this increase in CO (??) (HR increases slightly in first/second stages?) -BP increases during contractions (systolic increases more.) -WBC increases during labor (cause is unknown,) but can be due to tissue trauma. -Flushed cheeks, hot/cold feet, and eversion of hemorrhoids may appear. Respiratory changes: There's an increase in RR during labor due to increase PA with greater oxygen consumption. -Hyperventilation can cause resp. alkalosis, hypoxia, and hypocapnia (decrease in Co2.) In the unmedicated woman during the second stage of labor, o2 consumption almost doubles. Renal changes: Proteinuria of 1+ is normal; happens in response to the breakdown of muscle tissue from the physical work of labor. Integumentary system: Stretching of the vagina, minute tears in the skin around the vaginal introitus occur Musculosketal changes: diaphoresis, fatigue, and increased temperature occur from increase in muscle activity. Backache and joint aches occur as a result of increased joint laxity at term. Neurological changes: Euphoria from endogenous endorphins; these also raise the pain threshold and produce sedation, decreased perception of pain GI changes: GI motility is slowed, absorption of foods are decreased, stomach emptying time is slowed. Nausea/blenching may occur as a reflex response to full cervical dilation. Endocrine changes: Onset of labor may be caused by DECREASING levels of progesterone and INCREASING levels of estrogen, prostaglandins, and oxytocin. Metabolism also increases during labor, Blood glucose levels decrease with work of labor.

Stages and phases of labor (4) **Look and go off of LO, not lecture notes

First Stage - Onset of contractions to complete cervical dilation (10cm) (Longest stage of 4 stages) -Latent Phase - onset to increased dilation rate (0-3 cm) · When contractions first begin to a dilation of 3cm (Slower than active phase) (Longest part) -BP, pulse, RR, uterine activity and FHR should be assessed every 30-60 min. -Active Phase - 4-7 cm · Rate of dilation occurs more rapidly, about 1cm per hour of dilation (speeds up) -Transition - 8-10 cm · Quickest and most rapid part, before pushing begins -BP, pulse, RR, FHR, uterine activity, presence of blood show should be assessed every 15-30 min. (for active and transition phase) Second Stage - Complete cervical dilation (10cm) to birth of the baby (Begins at 10 cm when cervix is completely dilated and thinned and ends with the birth of the baby) This is the pushing stage!! -This stage can involve PASSIVE DESCENT (where mother is not actively pushing and baby still is moving downward.) Uterus contracts and muscles shorten, causing the baby to be pushed out because the uterus is trying to return to it's pre-pregnant size. -It can also involve Voluntary maternal expulsive effort (Pushing) should involve open glottis techniques (expelling air with pushing) -Controlled extension and expulsion as the baby's head/body emerges · Minimizing of perineal trauma -Assess maternal BP, pulse and RR assessments every 5-30 min -Assess FHR and pattern every 5-15 min depending on risk status -Assess vaginal show, signs of fetal descent, changes in maternal appearance, mood, affect, energy level, and involvement of partner/coach every 10-15 min -Assess every contraction and bearing-down effort -Latent phase: (also called delayed pushing, laboring down, passive decent) is a period of rest and relative calm. During this phase the fetus descends passively though the birth canal and rotates to an anterior position (from UCs.) The urge to bear down is not strong (some women do not experience it at all.) -Active pushing phase: The woman has strong urges to bear down (Ferguson reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor.) This stimulates the release of oxytocin from the posterior pituitary gland which causes stronger impulsive uterine contractions. Contractions come every 2-3 min progressing to every 1-2 min, duration for 90 seconds -Bearing down efforts become rhythmic. -The woman's experience of pressure, stretching, and straining should be validated as normal and a signal that the decent of the fetus is progressing and that her body is capable of withstanding birth. -**The only certain objective sign that the second stage of labor has begun is the inability to feel the cervix during vaginal examination (indicating it's fully dilated and effaced**) -Women who are laboring without regional anesthesia can experience an irresistible urge to push before cervical dilation. (can happen as early as 5cm.) This is most often related to the station of the presenting part below the level of the ischial spines. If the cervix is not yet dilated enough, encourage the woman breathe through her contractions using shallow, frequent panting of puffing breaths like she is blowing out a candle and to assume side lying position or hands/knee position to avoid pushing. -Perform physical assessment every 5-30 min (BP, pulse, RR,) FHR and pattern every 5-15 min. Third stage - Birth of the baby to delivery of the placenta (shortest stage of labor)** All about delivering the placenta! -Assess maternal BP, pulse and RR every 15 min -Assess for signs of placental separation and amount of bleeding -Assist with determination of Apgar score at 1 and 5 min after birth -Assess maternal and partner response to completion of birth process and their reaction to the newborn -Normally the first few strong contractions that occur after the baby's birth cause the placenta to shear away from the basal plate. -Signs of placental separation include lengthening of the umbilical cord and a gush of blood from the vagina. -Passive management is when the placenta comes out naturally -Active management (What we do) = we give oxytocin immediately after birth of baby to get the placenta to come out faster and prevent hemorrhage. Immediately after the placenta is birth, the fundus is massaged. At this time the nurse obtains a blood sample from the umbilical cord to determine baby's blood type and Rh status. Fourth Stage - First 2 hours after birth -Begins with the expulsion of the placenta and lasts until the woman is stable (From birth of placenta --> first 2 hours after birth.) -During this time, maternal organs undergo their initial readjustment to their nonpregnant state and systems begin to stabilize. -For healthy women, hemorrhage is the most dangerous potential complication during the fourth stage of labor. -BP and pulse need to be assessed every 15 min for the first 2 hours after birth. Temperature should be assessed every 4 hours for the first 8 hours after birth, then 8 hours after that. -Many women begin breastfeeding immediately after birth (30 min-1 hour) to stimulate the production of oxytocin (which promotes contraction of the uterus and prevents hemorrhage**) -Assess BP, pulse every 15 min for the first 2 hrs -Assess temp at the beginning of the recovery period, then every 4 hrs for the first 8 hrs after birth, then every 8 hrs -Assess fundus -Assess bladder -Assess lochia (vaginal discharge in the first few weeks after birth) -Assess perineum But... Is 6 the new 4? -New literature suggests 3cm may not be the end of the latent phase, some women do not enter the active phase until 5/6cm sometimes. Depends on individual variation (first stage of labor)

Episiotomies

Episiotomy: an incision sometimes made to increase the size of the opening of the vagina to allow the baby to pass Can be cut obliquely (rare, cut sideways, does not heal nicely and goes into inner thigh)- Because there's a short perineum and they do not want to cut into the anus Episiotomy: an incision made in the perineum to enlarge the vaginal outlet. 10% of births in the US do these but based on lack of evidence that episiotomy's are beneficial, we want to avoid these whenever possible.

Fetal location: Fetal Lie (what are the primary two lies?) Attitude (What attitude is best for birth?) Presentation (What are the 3 presentations?) Position Station Engagement

Fetal Lie: vertical lie (spine is parallel to mother's spine,) horizontal lie (perpendicular to mothers spine,) Oblique (diagonal) -Is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. The primary two lies are longitudinal (up/down)/ vertical (up/down) (which means both the baby and mothers' spines are aligned,) and transverse, horizontal, or oblique (all are variations of the baby lying sideways.) Vaginal birth cannot occur when the fetus stays in a transverse lie (Sideways)** -A baby in a horizontal lie, meaning that the long axis or spine of the baby is perpendicular to mothers rather than parallel, is also called a transverse lie, and as you can see from the figure in the lower right, is not amenable to vaginal birth, because the diameters that are presenting will not fit through the pelvis. This is an unusual presentation. (Know Frank breech, single footling breech, complete breech, shoulder presentation**) Attitude: refers to degree of flexion or extension of the baby's presenting part (usually head). Can either be in flexion (Default way, what we want, face down coming out,) Military attitude, non-flexion (looking straight ahead,) and extension (we want it to be in flexion) -The most favorable attitude is one of complete flexion (see pic) -Is the relation of the fetal body parts to one another. The fetus assumes a characteristic posture (attitude) in utero. Deviations from the normal attitude can cause difficulties in childbirth. -Normally, the fetus chin is flexed on their chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees. The arms are crossed over the thorax, and the umbilical cord lies between the arms/legs (This is called General flexion) -When the head is in complete flexion, it allows the fetal head to pass through the true pelvis easily. (Chin tucked down to chest.) If the head is more extended, the anteroposterior diameter widens, and the head may not be able to enter the true pelvis. Presentation: refers to anatomical part of the baby that is coming through the birth canal first. Use occiput as a reference point (occiput coming first in flexion birth.) If the baby is breach, they come out butt first (sacrum) or foot breach. Can also have a shoulder presentation (shoulder coming first,) Funic presentation (umbilical cord is coming out first) -Refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor. The presenting part of the fetus is what lies closest to the internal os of the cervix. It's the part felt when the examiner feels inside the uterus. -Cephalic presentation: headfirst (97% of births) (we feel the occiput) -Breech presentation: buttocks, feet, or both first (3% of births) (usually feel the sacrum) -Shoulder presentation: Shoulders first? (less than 1% of births) (we feel the scapula) Position: Is the relationship of a reference point on the fetal presenting part (occiput, sacrum, mentum (chin,) or sinciput (deflexed vertex) to the four quadrants of the mother's pelvis. (page 320 in book) -When the head is down and flexed, we use the reference point of the occiput to locate the baby's position. -Uses three-part abbreviation. The first letter represents the location of the presenting part in the (R) right or (L) left side of the mother's pelvis. -The second letter (middle) stands for the specific presenting part of the fetus (O = occiput, S = sacrum, M = mentum (chin,) and Sc = Scapula (shoulder) -The final letter stands for the location of the presenting part in relation to the anterior (A), posterior (P), or transverse (T) portion of the maternal pelvis. (Anterior is front of body, posterior is back of body) -Remember that the middle letter is about a reference point on the baby, and the other two letters are about reference points on the mother -Be careful of the word "facing", as in the baby is facing the mother's spine, because we are not using the face as our reference point. -ROA = means the occiput is the presenting part and is located in the right anterior quadrant of the maternal pelvis. · Posterior = towards back of mom (pelvis) · Anterior = towards front of mom (pelvis) Station: is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of degree of descent of the presenting part of the fetus through the birth canal. -We measure the station in cm above or below the ischial spines. -1cm above the spines is notes as "-1" -At the level of the ischial spine = 0 -When the presenting part is 1 cm below the spine = +1 -Birth is imminent when the presenting part is +4/+5 cm Engagement: term used to indicate that the largest transverse diameter of the presenting part (usually the biparietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0. -Often occurs weeks just before labor begins in nulliparas or just before/during birth for multiparas.

What are some fetal adaptations that occur during labor? -Normal FHR? -When is FHR higher, before term or term? -Temporary accelerations/decelerations (why do they occur, are they normal?) -What factors affect fetal circulation?

Fetal heart rate: FHR monitoring gives us information about the fetal oxygenation status. The average FHR at term is 140 BPM with a range of 110-160 BPM. Earlier in gestation, FHR is higher (average of 160 BPM,) as pregnancy progresses the rate decreases. -Temporary accelerations and slight early decelerations of FHR are normal and to be expected in response to spontaneous fetal movement, vaginal examination, fundal pressure, uterine contractions, abdominal palpation, and fetal head compression. Fetal circulation: is affected by factors like maternal position, uterine contractions, blood pressure, and umbilical cord blood flow. -Uterine contractions during labor tend to decrease fetal circulation. Most healthy fetuses are able to compensate for this stress* -Usually the umbilical cord moves freely in the amniotic fluid, but it can become compressed during uterine contractions

What is the most accurate way of assessing the intensity of uterine contractions and resting tone of the uterus?

Internal electric monitoring with intrauterine pressure catheter

Fetal assessment during labor Leopold maneuvers

Leopold maneuvers: are performed using abdominal palpation. They help the nurse determine: 1) Which fetal part is in the uterine fundus 2) Where the fetal back is located 3) what is the presenting fetal part

Suboccipitobregmatic diameter

Smallest anteroposterior diameter of the fetal skull to enter the maternal pelvis when the fetal head is in complete flexion The smallest and most critical one is the suboccipitobregmatic diameter

Where would the fetal heart tones most likely be located in a vertex presentation?

The left or right lower abdominal quadrant (under umbilicus) (two cm above the umbilical at midline would be appropriate for breeched baby?)

What are the 7 Cardinal movements of labor

The cardinal movements of labor and birth refer to the series of maneuvers the fetus makes as it navigates her/his way through the birth canal and out into extrauterine life. These maneuvers happen in a sequence that is designed to aid the baby in descending through the bony pelvis and its complicated geometric planes, as well as passing through the softer tissues of the uterus, cervix, vaginal canal, and perineum. 1) Engagement and decedent: The first cardinal movement occurs as the baby assumes a posture that presents the smallest diameter of the fetal head in an orientation to the largest diameter of the pelvic inlet. Engagement and descent occur as the baby moves inward and downward into the pelvis. The mother will describe this as the baby "dropping" and will feel less pressure under the rib cage and more pressure in the pelvis. This cardinal movement can occur prior to the onset of perceptible labor (lightening) -Engagement: When the Biparietal diameter (largest diameter of the fetal head) of the head passes the pelvic inlet, the head is said to be engaged in the pelvic inlet. -Descent: refers to the process of the presenting part through the pelvis. It depends on at least 4 forces: 1) pressure from amniotic fluid, 2) direct pressure from contracting fundus on the fetus, 3) force of the contraction of the maternal diaphragm and abdominal muscles in the second stage of labor, 4) extension and straightening of the fetal body -The degree of descent is measured by the station of the presenting part. -Little descent occurs during the latent stage of labor, it speeds up during the active phase when the cervix is dilated to 5-6cm. (happens even faster when membranes are ruptured) -First time labor = descent is slow but steady. In subsequent pregnancies, it descent may be rapid. -Progress of descent is measured by the presenting part; vaginal examination can be seen at the introitus (vaginal opening)* 2) Movement of Flexion: As the baby moves into the pelvis, the head will bend forward at the neck so that the baby's chin flexes down toward the chest. This movement of flexion creates the smallest possible diameter of the vertex (top of the baby's head) so that further descent and accommodation by the maternal pelvis can occur. Usually the baby is born with the face facing the floor. -As soon as the descending head meets resistance from the cervix, pelvic wall, or pelvic floor, it normally flexes (down) so the chin is brought closer to the fetal chest. -Flexion permits the smaller suboccipitobregmatic diameter (9.5cm) rather than a larger diameter to present to the outlet. 3) Internal Rotation: As the baby descends further into the pelvis, he/she needs to make a turn to navigate the changing planes of the pelvic bones. When you look at a model of the bony pelvis, you will see two prominent bony protuberances jutting into the pelvic cavity...these are called the ischial spines and mark the point known as the midpelvis. It is the narrowest part of the pelvis and the baby will rotate internally in a corkscrew fashion so that it moves from looking at the mothers side to looking at the mothers spine. Completing this rotation will line the baby up to come through the last part of the birth canal in a face downward orientation -Begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. As the occiput rotates anteriorly, the face rotates posteriorly. The head is almost always rotated by the time is hits the pelvic floor. Anterior rotation is being achieved* 4) Extension: The baby's head emerges into the world by moving in an upward and outward direction. This is called extension. -When the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum. The head emerges by extension; first the occiput*, then the face, and finally the chin. 5 & 6) External rotation/ Restitution: Once the baby's head has emerged, the baby needs to make another rotational maneuver to line the shoulders up in an anterio-posterior line to fit through the pelvic outlet. Usually, the baby will rotate to the same position in which he/she entered the pelvis, looking at the mother's right or left thigh. -After the head is born, it rotates briefly to the position it occupied when it was engaged in the inlet. (this movement is referred to as restitution.) The 45-degree turn realigns the infants head with the back and shoulders** -The head can then be seen to rotate further; this external rotation occurs as the shoulders engage and descend in maneuvers similar to those of the head. -Anterior should descends first, when it reaches the outlet, it rotates to the midline and is delivered from under the pubic arch. 7) Expulsion: (not shown) Once restitution is complete, the shoulders emerge (usually the anterior then the posterior shoulder), and the rest of the baby's body is born quickly by expulsion. (last movement of labor is expulsion) -After the birth of the shoulders, the head and shoulders are lifted up towards the mothers pubic bone and the trunk of the baby is born by flexing it laterally in the direction of the symphysis pubis. -When the baby has emerged completely, birth is complete and the second stage of labor ends. Elasticity in the pelvis from progesterone and relaxin hormone help the pelvis open up and move slightly to accompany the birthing process

Assessment of FHR and pattern Where is the point of maximal intensity (PMI) heard?

The point of maximal intensity (PMI) of the FHR is the location on the maternal abdomen where FHR is heard the loudest (usually directly over the fetal back) (Vertex presentation = heard below the umbilicus, breech presentation = heard best above the mothers umbilicus.) The nurse must check FHR regularly, if the baseline rate begins to slow, if absent or minimal variability occurs, or if abnormal (late, variable, or prolonged) deceleration patterns develop, interventions are instituted promptly. 1) first action is to turn woman on her side to reduce the pressure of the uterus against the great vessels 2) Oxygen can be administered via nonrebreather 10 L/min These are often the only interventions needed to restore a normal pattern, if FHR does not improve, the next step is to notify the nurse-midwife or physician

Why do we give oxytocic medications (oxytocin, Pitocin) immediately after birth of the infant?

We give this medication immediately after expulsion to increase contractions more and to have the placenta deliver? And to decrease risk of hemorrhage?

Single footling breach

foot dangling down

Frank breach

hips flexed, knees extended See pic*

ROT

right occipital transverse This means that the occiput (O), is located on the right side of the mother (R), and that occiput is neither toward the mother's sacrum nor her symphysis, but is completely to the side of her pelvis or transverse (T). Therefore, this baby is ROT.

ROP

right occiput posterior Occiput is posterior (facing towards back of mom)

What is the definition of comfort

"The state of having addressed basic needs for ease, relief, and transcendence met in 4 contexts of experience (physical, psychospiritual, sociocultural, and environmental)" "I believe the opposite of comfort is suffering"* As we Nurses, we want to promote comfort, not relieve all pain?

A patient states that water is leaking from her vagina, what is the first question a nurse should ask during assessment?

"When are you due to have your baby?" Rupture of membranes may be normal for her point in pregnancy or abnormal if she is not to term.

5 P's of birth: Position of mother

4) Position of mother: Frequent changes in position reduce fatigue, increase comfort, and improve circulation. For many years, and still today, horizontal positions for birthing have been common. (Horizontal position is the least favorable for the baby's passage their the birth canal/bony pelvis) - Lithotomy, supine positions are used most commonly -These positions have the advantage of allowing easy access and visualization of the perineum by the doctor or midwife and are congruent with the configuration of birthing beds in most hospitals. However, as we have learned from our review historical depictions of birthing and what we know of the other P's, horizontal positions are not the most favorable for progressive birth, as they do not permit the use of gravity to support fetal descent. The configuration of the pelvis requires that the baby's head move upward in extension at the time of birth and this movement can be inhibited by the mother's position in bed** Alternative birthing positions: -Vertical positions use the downward forces of gravity to support fetal descent and permit the pelvis to open to its widest dimensions. -The coccyx for example, is a hinged joint at the bottom of the sacrum, which can move backwards to permit more room at the pelvic outlet when there is not counterpressure to constrict it. Frequent maternal position changes not only offer various methods for using gravity to support labor progress, but also represent a distraction, which can modify sensations of discomfort. In addition, varying positions permits the woman and her partner to make use of other labor support techniques, such as rocking, massage, and hydrotherapy. Alternating maternal positions can also encourage internal rotation of the fetus into a more favorable orientation for descent. For example, Lunging and hands and knees positioning can encourage a baby in an occiput posterior position to rotate to an occiput anterior one and relieve back pressure for the mother. Squatting with the knees apart opens the pelvic outlet to enhance descent and extension, while making full use of the forces of gravity. Women should alternate positions so that there are periods of activity and rest to conserve energy

What is an Asynclitic birth (Asynclitism)

An asynclitic birth or asynclitism refers to the position of a fetus in the uterus such that the head of the baby is presenting first and is tilted to the shoulder, causing the fetal head to no longer be in line with the birth canal - Baby cannot descend through the maternal pelvis. Birth usually occurs in a synclitic position meaning the head is aligned with the pelvis.

First stage of labor signs

First stage of labor: -Early phase: 0-5cm, nulliparous and multiparous women progress at similar rates. Strength of contractions is mild to moderate by palpation, frequency is 2-30 min apart, may be irregular and the duration is 30-40 seconds. Brownish discharge, mucus plug, or pale pink mucus may occur. -Active phase: 6-10cm, multiparous women progress more rapidly than nulliparous women, strength of contractions is moderate to strong by palpitation, frequency is 1.5-5 min apart, and duration is 40-90 seconds. Station of presenting part = for nulliparous women, 0 by 6cm. For multiparous women, -1 by 6cm.

What are the 5 P's of labor and birth?

Labor happens in the presence of a series of forces and resistances that can promote or impede successful vaginal birth. We refer to the dimensions of forces and resistances as the 5 P's. 1) Passengers (fetus and placenta) 2) Passageway (birth canal) 3) Powers (contractions) 4) Position of mother 5) Psychologic response

What is a lotus birth?

Lotus birth: when the cord is not clamped and cut at all; instead, they remain attached to the baby until the cord naturally separates from the baby several days after birth.

Bishops Score Which score indicates a ripe cervix?

Scores are assigned in 5 categories and total score ranges from 0 - 13 Scores greater than 7 indicate a "ripe" cervix - prepared for labor onset or amenable to induction The Bishop's score is a method of determining how ready the cervix is to open under the influence of contractions and fetal head pressure. Allows us to assess the ripeness of the cervix (can allow us to assess how close to labor/D they are and make decisions about inducibility of labor.) If cervix is not ripe or ready to get thinner, induction (contractions) will not be successful. We don't want to start induction on an un-ripe cervix.

5 P's of birth Psychologic response

Psychologic response: Examines the mind/body connection and the role that the mind/thoughts play on physical functioning** We should address the patient fears, because they make pain responses worse and result in catecholaminerelease (Slowing down contractions and labor process) o Ambivalence (Mixed feelings) o Anticipation o Anxiety o Culture o Expectation o Experience o Fear o Preparation o Pain/Comfort perception, appraisal, response, and management o Spirituality o Support and supportive resources o Stress and stress responses Psyche refers to the emotional, perceptual, and psychological appraisal of the sensations of labor and birth. Research is ongoing into the powerful influence that the mind has on the functions of the body, and nurses are ever aware of the mind-body connection in health and healing. Animal studies demonstrate that birth processes and outcomes are inhibited by fear. Lab animals have higher rates of fetal death and birth disorders when subjected to stressful conditions during pregnancy and birth. Humans demonstrate disorders of labor, including both preterm and prolonged labor and higher rates of cesarean section when they are stressed or fearful. Individual variations in perception, appraisal, and responses to body sensations such as muscle contraction, ischemia, and tissue stretching, influence the range of painfulness reported during birth. Preparation, conditioning, desensitization, and other strategies before and during labor can modify the experience with the goal of improving safety and satisfaction with birthing. Pregnant women are exposed to vicarious experiences for birthing from media images and stories from relatives and friends. This programming can counteract efforts to remain calm and positive when the messages focus on dramatic and drastic outcomes. Nurses can support a realistic and positive perception of birthing through education and reassurance

What are some signs of developing complications during labor/birth? Intrauterine pressure Resting tone Contraction length Number of contractions in a 10 min window Relaxation between contractions

o Intrauterine pressure equal to or greater than 80 mm Hg or resting tone equal to or greater than 20 mm hg (both determined by internal monitoring with IUPC) o Contractions lasting longer than 90 seconds o More than 5 contractions in a 10 min period (contractions that occur more frequently than every 2 min) o Relaxation between contractions lasting less than 30 seconds o Fetal bradycardia or tachycardia. Absent or minimal variability not associated with the fetal sleep cycle, medications. Late, variable, or prolonged FHR decelerations. o Irregular FHR; suspected arrhythmias o Appearance of meconium stained or bloody fluid from the vagina o Maternal temp greater equal to or greater than 38 C (100.4 F) o Foul smelling vaginal discharge o Persistent bright or dark red vaginal bleeding

Which position is most optimal for the fetus to be in during labor/birth?

Anterior positions are more favorable for birth, because they favor the face down aspect compared to posterior which result in a face up birth Occiput anterior* is most favorable or ROA, LOA

5 P's of birth: Passenger Most common presentation for a baby during labor? Ways that fetal anatomy favors birth? What is the largest portion of the fetal head called? Suboccipitobregmatic diameter? What fontanelle can the examiner palpate when doing an examination?

1) Passenger: The way the passenger (fetus) moves through the birth canal is determined by size of the fetal head, fetal presentation, fetal lie, fetal altitude, and fetal position. (Placenta is also considered a passenger because it is birthed after the fetus.) The placenta rarely interferes with the birthing process except for Placenta previa (complication.) The most common presentation for a baby during labor and vaginal birth is called the vertex presentation (This means that the baby's head will emerge first, in an attitude of complete flexion.) The passenger (baby) has the ability to accommodate to the maternal pelvis during birthing because of the rotational movements he/she undergoes during descent, which are largely passive until the expulsive phase. Another feature of fetal anatomy that favors the vaginal birth process is the ability for the cranial diameters to become smaller. In fetal life the bones of the cranium are not yet fused. Because the cranial bones are not yet fused, they have the ability to come together and overlap each other, functionally reducing the diameter of the head as it passes thru the pelvis. The largest transverse diameter of the baby's head is called the biparietal diameter, because is it measured as the distance between the two parietal bones at their widest part. When this diameter passes into the pelvic inlet, the very top of the baby's head can be found at a 0 station. This is called engagement. When the baby is in complete flexion, the anterio-psoterior diameter that presents itself into the pelvis is called the suboccipitobregmatic diameter. In this positon, the smallest diameter of the head (the occiput) is presenting. During cervical examination in labor, the examiner will be able to easily palpate the posterior, but not the anterior fontanelle.

5 P's of birth: Passageway What makes up the passageway? What 3 planes of the bony pelvis does the baby need to navigate through during labor and birth?

2) Passageway: or birth canal, is composed of the mother's rigid bony pelvis and the soft tissues of the cervix, the pelvic floor, the vagina, and the introitus (the external opening of the vagina.) The fetus must successfully accommodate itself through the rigid passageway of the pelvis. Each of these structures can be configured by both modifiable and non-modifiable variables. These variables can present favorable conditions. For example, women who have variations or congenital abnormalities of the pelvis may have pelvic diameters that do not favor vaginal birth. Traumatic injuries or prior surgeries on the pelvis or cervix, may likewise render the structures less able to accommodate an emerging baby. The bony pelvis contains 3 imaginary planes that the baby needs to navigate during labor and birth. These 3 planes are called the inlet, the midpelvis, and the outlet. Recall that, although the bony pelvis is rigid, the hormone relaxin acts on the cartilage and joints holding the 5 pelvic bones together, which allows whole pelvic cage to have more laxity and expandability The uterine muscle will passively contract and relax before and during labor (see powers) and the cervix softens, thins, and dilates in response to both uterine contractions and changes in the chemical structure of those tissues. The ligaments and muscles of the pelvic floor aid in molding and guiding the fetal presenting part through the pelvic cavity

5 P's of birth: Powers What is the difference between primary and secondary powers? What are effacement and dilation?

3) Powers: Involuntary and voluntary powers combine to expel the fetus and placenta from the uterus. Primary powers: are the involuntary uterine contractions that start at the beginning of labor. These involuntary contractions originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment. Contractions move downward in waves, separated by short rest periods. (The primary powers are responsible for the effacement and dilation of the cervix and descent of the fetus.) -Effacement (shortening and thinning of the cervix) occurs during the first stage of labor. Muscle bundles shorten (in the uterus) during contraction. The degree of effacement is calculated from 0-100% -Dilation: of the cervix is the enlargement or widening of the cervical opening; it increases from less than 1cm to full dilation (10cm) to allow birth of the fetus. *When the cervix is fully dilated and completed retracted, it can no longer be palpated by an examiner. Full dilation marks the end of the first stage of labor. Contractions cause the cervix to draw upwards. Pressure by the amniotic fluid or from force of the presenting part can promote cervical dilation. When the presenting part of the fetus reaches the perineal floor, mechanical stretching of the cervix occurs. -Stretch receptors in the posterior vagina cause the release of endogenous oxytocin that triggers the maternal urge to bear down (Ferguson reflex) Secondary powers: start once the cervix is dilated (bearing down efforts of the woman.) These are voluntary (the woman purposefully pushes) along with the involuntary contractions (they work together.) -When the presenting part reaches the pelvic floor, the contractions change in character and become expulsive. The woman experiences an involuntary urge to push. -Bearing down efforts help compress the uterus on all sides and adds to the power of expulsive forces. -Secondary powers have no effect on cervical dilation* (at this point, the woman should already be fully dilated?) Uterine contractions are called the primary powers and are designed to promote cervical effacement and dilation as well as fetal descent. Uterine contractions are assessed for their frequency, duration, intensity, and regularity, because these are the features of functional uterine activity that contributes to progress in labor. Contractions are involuntary powers, however, the secondary powers of maternal expulsive efforts are voluntary** At the beginning of the expulsive stage, mother's without regional anesthetics experience an overwhelming reflexive, bearing down urge.

What is cervical ripening

As we approach birth, the cervix starts to go through RIPENING. It gets softer, starts to open to prepare for birth. It gets thinner (effacement.) Dilation process of oz (opening of cervix) goes from 0 cm to about 10cm (about size of newborn baby head to pass through the vagina)

Bearing down/pushing

Bearing down: Occurs when fetal head reaches the pelvic floor. She will want to bear down by contracting abdominal muscles while relaxing the pelvic floor (involuntary response to the Ferguson reflex.) Women should be encouraged to push as they feel the need to do so (instinctive, spontaneous pushing) rather than to push on command (directed, closed glottis pushing.) Prolonged breath holding while closing her glottis is strongly discouraged because it may trigger the Valsalva maneuver (when the woman closes her glottis) causing decreased CO and decreased perfusion to the uterus/placenta. Encourage open glottis pushing and breathing while pushing!! The nurse should advocate for delayed and spontaneous bearing down efforts with the woman in the upright lateral position. Spontaneous open-glottis pushing (bearing down while exhaling) for 6-8 seconds at a time is encouraged.

How/why does labor begin? Theories of labor initiation? -Hormonal (maternal vs fetal/placental) -Mechanical How do estrogen, progesterone, oxytocin, and prostaglandins react to labor? (increase/decrease)

How/Why Does Labor Begin? = We don't exactly know! Theories of Labor Initiation: -Hormonal factors (Signal body to begin labor) -Maternal: -Progesterone levels drop relative to estrogen levels (may cause labor?) -Fetal/placental - placenta and fetal adrenals secrete CRH (Corticotropin-releasing hormone) - crosses placenta to increase maternal estrogen levels (which contributes to the changing estrogen/progesterone levels) -Mechanical -Uterine distension -Uterine Contractions -Cervical Ripening (Cervix softens and begins to thin out) We do not know the exact cause of true labor. Many factors contribute; Hormones produced by the normal fetal hypothalamus, pituitary and adrenal cortex probably contribute to the onset of labor Increased estrogen, oxytocin, and prostaglandins and decreasing levels of progesterone* occur.

Assessments of the newborn Why do we do delayed cord clamping?

Immediate skin to skin contact and delayed cord clamping is recommended. Immediate skin to skin contact has been shown to positively affect maternal-infant bonding, breastfeeding duration, cardiorespiratory stability and body temp. The umbilical cord should not be clamped until 1-5 min after birth or until the cord stops pulsating. This allows the physiologic transfer of blood to the newborn; transfusion of up to 30% of placenta blood volume Cut the cord about 2.5 cm above the clamp

Membrane rupture

Membrane rupture: can occur anytime in the active phase of the first stage of labor. Artificial rupture of membranes (AROM) is discouraged if there is no medical reason for it because it can increase the laboring woman's sensation of pressure and pain and is not necessary for a normal birth to occur. (The umbilical cord may prolapse when membranes rupture.)

Assessing uterine contractions by palpation Mild Moderate Strong

Mild: slightly tense fundus that is easy to indent with the fingertips (feels like pressing finger into tip of nose) Moderate: Firm fundus that is difficult to indent with the fingertips (feels like pressing finger into a chin) Strong: rigid, board like fundus that is almost impossible to indent with fingertips (feels like pressing fingers into a forehead)

Normal measures of the pelvis inlet, cavity and outlet?

Pelvic inlet: 12.5-13cm Pelvic midplane (cavity): 10.5cm Outlet: greater than/equal to 8cm

What are the difference degrees of lacerations related to labor/delivery

Perineal: -1st degree - skin and superficial tissue* (most common) -2nd degree - through the perineal muscles* (most common) -3rd degree - into the anal sphincter muscle -4th degree - through the sphincter and into the rectal wall *Labial and periurethral lacerations are less common Vaginal vault laceration (surgical lacerations, more related to efforts of pushing when the cervix is not fully dilated) -rare Cervical: -Lacerations can occur at the time of delivery Perineal integrity of birth process: We can control how fast the baby head energizes from the birth canal. Guide the baby's head out of the perineal gradually instead of suddenly. -Maternal position at the time of birth can help as well (reduced risk of laceration) -Lubricants to help to minimize trauma/lacerations -Warm packs -Perineal massage Some degree of perineal trauma to the soft tissues of the birth canal and other structures occurs with every birth** Other risk factors associated with perineal trauma: Maternal nutritional status, birth position, pelvic anatomy (narrow subpubic arch,) fetal malpresentation and position (breech,) large infants, use of forceps or vacuum, prolonged second stage of labor and rapid labor. Injuries to the supporting tissues can cause GU and sexual problems later in life (pelvic relaxation, uterine prolapse, urinary and bowel dysfunction.) -Kegel exercises can help with these.

What are some physical and psychological comfort measures to provide the laboring mom?

Physical: -Positioning -Ambulation, movement -Massage - Counterpressure -Hydrotherapy -Progressive muscle relaxation -Acupressure -Breathing techniques -TENS - gate control theory of pain -Oral fluids -Vocalization -Sleep Psychological: -Hypnosis -Guided imagery -Music -Prayer -Psychoprophylaxis -Distraction -Presence of another* All are intended to help the woman's psyche toward remaining relaxed, empowered, and safe. Tailoring this toolbox of interventions to patient needs is the art of labor support and part of a relational dialogue with the woman and her support system.

What makes up the soft tissues of the passageway (birth canal) -Upper segment of the uterus during labor? Lower segment? -What is the pelvic floor

Soft tissues: Of the passageway include the lower uterine segment, the cervix, the pelvic floor muscles, the vagina and the introitus (vagina opening.) After labor begins, contractions cause the uterine body to have a thick and muscular upper segment and a thin-walled, passive, muscular lower segment. Contractions of the uterine body exert downward pressure on the fetus, pushing it against the cervix. The cervix effaces (thins) and dilates (opens) to allow first fetal portion to descend the vagina. As the fetus descends, the cervix is drawn upward and over the first portion. The pelvic floor is a muscular layer that separates the pelvic cavity above the perineal space below, it helps the fetus rotate anteriorly as it passes through the birth canal. Effacement generally progresses significantly in first term pregnancy before slight dilation occurs* In subsequent pregnancies, effacement and dilation of the cervix tend to progress together. -Epidural does not decrease the frequency or intensity of contractions

Suctioning after birth?

Suctioning: after birth should only be done for infants with resp. obstruction or those requiring positive pressure ventilation. Suctioning can induce bradycardia.

What are fontanels When do they close?

The fetal head is composed of two parietal bones, two temporal bones, the frontal bone, and the occipital bone. Tissue sutures hold the fetal skull together. The area where two bones meet are called fontanels. During labor and after rupture of membranes, palpation of fontanels and sutures during vaginal examination reveals fetal presentation, position, and attitude. Anterior fontanel closes by 18 months after birth Posterior fontanel closes 6-8 weeks after birth. (2 months) -The sutures and fontanels make the fetal skull flexible and able to accompany birth and let it pass through the mother's pelvis. -Heads of newborns go back to their original shape around 3 days after birth. There are about 6 fontanelles, but we generally concern ourselves with the two largest ones. The anterior fontanelle is a diamond shape opening behind the baby's forehead and the posterior fontanelle, located on the back of the head, is a smaller triangular soft spot

What are the 4 pelvic types? What is Cephalopelvic disproportion?

The four basic types of pelvises: 1) Gynecoid (the classic female type,) round/circle shape with wide subpubic arch (good for birthing) - 50% of all women 2) Android (resembling the male pelvis) is heart shaped, angulated, with narrow subpubic arch - 23% of all women 3) Anthropoid (oval shaped) with narrow subpubic arch - 24% of all women (non-caucasian) 4) Platypelvic (the flat pelvis) that has a wide subpubic arch. Mixed pelvic types are more common than pure types** Different pelvic types have different proportions of space, which can influence the ability of a baby to fit through. When there is a mismatch between the size or orientation of the baby's head and the size or proportions of the mother's pelvis, we call this condition cephalopelvic disproportion.... a long way of saying that the baby won't fit through the pelvis.

True labor contractions vs False labor contractions

True labor contractions: occur regularly, becoming stronger, lasting longer, and occurring closer together. They become more intensive with walking/activity, are usually felt in the lower back, radiating to the lower portion of the abdomen, and continue despite comfort measures. False labor contractions: occur irregularly or become regular only temporary, often stop with walking or position change (activity,) can be felt in the back or abdomen above the umbilicus, can often be stopped through the use of comfort measures.

Anatomy of a contraction Difference between Braxton hicks contractions and true contractions?

Uterine contractions occur throughout pregnancy and can begin as early as the first trimester. Non-painful tightening's of the uterine muscle are called Braxton-Hicks contractions. These can be felt spontaneously or when the mother has a full bladder, walks up a flight or stairs, or becomes dehydrated. -As long as there is no regular pattern to these, there is no discomfort involved, and there is no accompanying cervical change, these are not considered part of labor** (not a true contraction) A true labor contraction vs a false one has to do with its impact on cervical change. If there IS a regular pattern, discomfort, and cervical change... These are considered true contractions and are a part of labor. (Contraction intensity increases, peak to contraction, and decline where tightening relaxes)

Why do we discourage solid foods in labor? IV fluid caution? How often should women void during labor? Bowel elimination?

We recommend avoiding solid food during labor in case the woman has an emergency and needs to go under general anesthesia. (Only clear liquid, ice chips, NPO during the active phase of labor) IV fluids: done to maintain hydration during labor; We need to watch for fluid overload though. Pregnant women are at an increased risk of hypervolemia related to fluid retention that occurs during pregnancy. Voiding: Women should be encouraged to void every 2 hours; a distended bladder can impede descent of the presenting part, slow or stop uterine contractions, lead to decreased bladder tone/atony after birth. (Epidural puts women at increased risk for retention of urine) Bowel elimination: most women do not have bowel movements during labor because of decreased intestinal motility.

What is the biparietal diameter?

Widest part of head entering the pelvic inlet; largest transverse diameter that measures approximately 9.25 cm When the fetus has their neck flexed (chin down) the biparietal diameter decreases and helps them pass through the birth canal.

What are some suggested measures for supporting a woman in labor?

o Preparation and support o Provide companionship and reassurance. o Offer positive reinforcement and praise for her efforts. o Encourage participation in distracting activities and nonpharmacologic measures for comfort. o Give nourishment (if allowed by primary health care provider). o Assist with personal hygiene. o Offer information and advice. o Involve the woman in decision making regarding her care. o Interpret the woman's wishes to other health care providers and to her support group. o Create a relaxing environment. o Use a calm and confident approach. o Support and encourage the woman's support people by role-modeling labor support measures and providing time for breaks

ROA

right occiput anterior Occiput is anterior (facing towards front of mom) and towards the right when the baby's occiput is still toward the mother's right side but is rotated more toward the pubic bone or the anterior (outer) part of the mother. Remember that the middle letter is about a reference point on the baby, and the other two letters are about reference points on the mother. Be careful of the word "facing", as in the baby is facing the mother's spine, because we are not using the face as our reference point.