Chapter 15
palpate woman fundus for ... and observe...
Palpate a woman's fundus for size, consistency, and position and observe the amount and characteristics of lochia each time you record vital signs.
Step 3 Leopold
Position the woman supine with knees slightly flexed. Place a small pillow or rolled towel under her left side. Flexing the knees relaxes the abdominal muscles. Using a pillow or towel tilts the uterus off the vena cava, preventing supine hypotension syndrome.
third stage labor/placental stage
lasting from the time the infant is born until after the delivery of the placenta
why is contractions longer than 70 seconds bad
long enough to compromise fetal well-being because this interferes with adequate uterine artery filling.
complete (breech)
longitudinal good (full extension) criss cross The fetus has the thighs tightly flexed on the abdomen; both the buttocks and the tightly flexed feet present to the cervix.
medical terminology
If giving a progress report, remember that most women are aware of the word dilatation but not effacement. Just saying, "No further dilatation," therefore, is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening and that's just as important" is the same report given in a positive manner
fetal tachycardia and bradycardia
above 160 or less than 110
labor intensity is so great that almost all _____ are involved
body systems
3 types of breech presentations
complete frank footling
Best approach that supports the woman as she focuses on her new family? (regardless of how many kids she's had!)
family centered nursing care
if fetal blood is obtained by scalp puncture, the finding of acidosis (<7.2) suggests...
fetal well being is becoming compromised and that further investigation is also necessary
How to fit through inlet of birth canal best
fetus must present transverse diameter (smaller) to the smaller diameter of maternal pelvis (DIAGONAL CONJUGATE), otherwise progress can be halted and vaginal birth may not be possible
umbilicus after birth
firm, round mass just below the level of the umbilicus.
maternal pelvis divided into 4 quadrants according to mothers right and left...
(a) right anterior, (b) left anterior, (c) right posterior, and (d) left posterior. our parts of a fetus are typically chosen as landmarks to describe the relationship of the presenting part to one of the pelvic quadrants.
Do not omit the word "pain." why?
-the term strengthens an understanding of the problem as well as alerts a woman she should feel free to ask for something for pain at the point she feels additional help
variability should be recorded as
Absent: No amplitude range is detectable. Minimal: Amplitude range is detectable but is 5 beats/min or fewer. Moderate (normal): Amplitude range is 6 to 25 beats/min. Marked: Amplitude range is greater than 25 beats/min. Other patterns in the baseline rate that can be detected include fetal bradycardia (FHR is lower than 110 beats/min for 10 minutes) and fetal tachycardia (FHR is faster than 160 beats/min for a 10-minute period).
after birth in third stage (uterine contractions)
After a few minutes of rest, uterine contractions begin again, and the organ assumes a discoid shape. It retains this new shape until the placenta has separated, approximately 5 minutes after the birth of the infant.
rupture considerations
If the fluid is malodorous, there could be an infection. If membranes rupture during labor, assess FHR immediately to be certain the umbilical cord hasn't prolapsed and is now being compressed against the cervix by the fetal head. The time of rupture is important because the potential time clock for an infection begins with ruptured membranes. It's preferable if the baby is born within 24 hours of rupture to reduce the risk of infection.
Increase in fetal BP can be cause by increased
ICP raises BP and keeps circulation from falling below normal for the duration of a contraction
uti symptoms
If a woman reports any symptoms that suggest a urinary tract infection such as burning on urination, blood in urine, extreme frequency, or flank pain, obtain a clean-catch specimen for culture.
Minus Stations
If the presenting part is above the spines, the distance is measured and described as minus stations, which range from −1 to −4 cm.
Plus Stations
If the presenting part is below the ischial spines, the distance is stated as plus stations (+1 to +4 cm).
if a woman membranes ruptured at home...ask her what?
If the woman's membranes ruptured at home, ask her to describe the color of the amniotic fluid, the amount, the odor, and the approximate time of rupture. Amniotic fluid should be clear as water. Yellow-stained fluid suggests a blood incompatibility between the mother and fetus (the amniotic fluid is bilirubin stained from the breakdown of red blood cells). Green fluid suggests meconium staining.
6th step vag exam
If there is no bleeding or cord visible, the examiner stabilizes the uterus by placing a hand on the woman's abdomen and then introducing the index and middle fingers of the other hand into the vagina, directing them toward the posterior vaginal wall. The posterior vaginal wall is less sensitive than the anterior wall.
intensity of contractions manually
If you are assessing manually, rate a contraction according to: Mild, if the uterus does not feel more than minimally tense Moderate, if the uterus feels firm Strong, if the uterus feels as hard as a wooden board or you are unable to indent the uterus with your fingertips at the peak of the contraction
Sinusoidal Pattern
In a fetus who is severely anemic or hypoxic, central nervous system control of heart pacing may be so impaired that the FHR pattern resembles a smooth, frequently undulating wave with a cycle frequency of 3 to 5 per minute and persisting 20 minutes or more. it is recognized to be as ominous as a late deceleration or variable deceleration pattern and so needs to be reported.
Abnormal pulse
Most women during pregnancy have a pulse rate of 70 to 80 beats/min. This rate normally increases slightly during the second stage of labor because of the exertion involved. A maternal pulse rate greater than 100 beats/min during labor is unusual and should be reported because it may be another indication of hemorrhage.
what is the most common fetal position
LOA and then ROA is second most frequent
murmur in pregnant women
Many pregnant women at term have a grade 2 to 3 systolic ejection murmur because of the extra volume of blood that must cross their heart valves. Document if this is noticeable.
palpable mass on breasts
Mark the chart of a woman who has a palpable mass in her breasts for reexamination after labor and birth. This is probably an enlarged milk gland but needs further evaluation to be certain it is not something more serious such as a breast malignancy.
Molding is caused by
Molding is caused by the force of uterine contractions as the vertex of the head is pressed against the not yet dilated cervix.
FHR monitors
Monitors are set with automatic alarms that trigger if an FHR goes below 110 beats/min or above about 170 beats/min and so may ring many times if a woman is active in labor. This causes their use to result in unnecessary cesarean births as well as frightened parents (which could adversely affect early parent-infant bonding). Monitoring does offer advantages from a healthcare provider's standpoint because observing the FHR on a monitor is quicker than listening with a Doppler and yields information on not only the rate but also on how the FHR responds to a forceful contraction. Use of monitors for a short-term initial assessment followed by intermittent manual monitoring is a compromise solution. Be certain to inform parents that the FHR can vary greatly during labor so they're not surprised when they see this and also that a monitor is only an aid and should not be the focus of their attention.
eye infection drops?
Most newborns receive prophylactic eye ointment against the possibility of a chlamydia infection. Don't administer this until after the parents have had this chance to see their infant for the first time
step 9 vag exam
Next is establishment of the fetal position. The fontanelle palpated is invariably the posterior one because the fetus maintains a flexed position, presenting the posterior not the anterior fontanelle. If it points toward an anterior quadrant, the position is ROA or LOA. In a breech presentation, the anus can serve as a marker for position.
step 8 vag exam
Next, the examiner locates the ischial spines, identifies the presenting part, and rates the station of the fetus. schial spines are palpated as notches at the 4 and 8 o'clock positions of the pelvic outlet. Station is the number of centimeters above or below the spines the presenting fetal part has reached. Identifying the presenting part confirms findings obtained with Leopold maneuvers. The vertex has a hard, smooth feel. Fetal hair may be palpable but massed together and wet, and it may be difficult to appreciate through gloves. Palpating the two fontanelles, one diamond-shaped and one triangular, helps identification. Buttocks feel softer and give under fingertip pressure. Identifying the anus may be possible because the sphincter action will "trap" an examining finger.
5th step vag exam
Note any fluid escaping from the vagina that could be amniotic fluid, in addition to the presence of the umbilical cord or bleeding. Amniotic fluid implies membranes have ruptured and the umbilical cord may have prolapsed. Bleeding may be a sign of placenta previa. Vaginal examinations should not be continued if a possible placenta previa exists.
evaluation of labor should be done when?
ONGOING to preserve the safety of the woman and her newborn. after birth, an evaluation helps determine the woman's opinion of her experience with labor and birth
Step 4 Leopold
Observe the woman's abdomen as to which is the longest diameter and where fetal movement is apparent. The longest diameter (axis) is the length of the fetus. The location of activity most likely reflects the position of the feet.
fetal hyperactivity concerning why
Ordinarily, a fetus remains quiet and barely moves during labor. Fetal hyperactivity may be a subtle sign that hypoxia is occurring because frantic motion is a common reaction to the need for oxygen.
some nursing diagnoses r/t labor
Pain related to labor contractions Anxiety related to process of labor and birth Health-seeking behaviors related to management of discomfort of labor Situational low self-esteem related to inability to use planned childbirth method
where to place transducers
Place the transducer snugly over the uterine fundus or the area where contractions are most easily felt. The transducer works to convert the pressure originated by the contraction into an electronic signal that is then recorded on graph paper.
discovering a shoulder presentation during labor is an important assessment because...
it almost always identifies a birth position that puts both mother and child in jeopardy unless skilled healthcare personnel are available to complete a cesarean birth.
increasing apprehension needs to be investigated for physical reasons too because
it can be a sign of O2 deprivation or internal hemorrhage
Just as important to report is a falling blood pressure because
it may be the first sign of intrauterine hemorrhage, although a falling blood pressure from hemorrhage is often associated with other clinical signs of hypovolemic shock, such as apprehension, increased pulse rate, and pallor.
if the placenta separates at edges first...the presentation is called...?
it slides along the uterine surface and presents at the vagina with the maternal surface evident. It looks raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces evident; this is called a Duncanpresentation.
if the placenta separates first at its center and lastly at its edges...what is the presentation then called?
it tends to fold on itself like an umbrella and presents at the vaginal opening with the fetal surface evident 80% of placentas do this appearing shiny and glistening from fetal membranes this is called a Shultze presentation
vertex
longitudinal good (full flexion) The head is sharply flexed, making the parietal bones or the space between the fontanelles (the vertex) the presenting part. This is the most common presentation and allows the suboccipitobregmatic diameter to present to the cervix.
Brow
longitudinal moderate (military) Because the head is only moderately flexed, the brow or sinciput becomes the presenting part.
Footling (Breech)
longitudinal poor Neither the thighs nor lower legs are flexed. If one foot presents, it is a single-footling breech; if both present, it is a double-footling breech.
Frank (breech)
longitudinal moderate holding its legs Attitude is moderate because the hips are flexed, but the knees are extended to rest on the chest. The buttocks alone present to the cervix.
Face
longitudinal poor The fetus has extended the head to make the face the presenting part. From this position, extreme edema and distortion of the face may occur.
Mentum
longitudinal very poor The fetus has completely hyperextended the head to present the chin, causing the presenting diameter (the occipitomental) to be so wide that vaginal birth may not be possible.
should vag exams be done in presence of fresh bleeding?
no! may indicate placenta previa (implantation of the placenta so low in the uterus that it is encroaching on the cervical os) is present.
is molding a permanent condition?
no, only lasts a day or two.
shiny is to _____ as dirty is to ______
sheltie presentation vs Duncan presentation (irregular maternal surface shows)
effacement
shortening and thinning of the cervical canal. 1-2 cm long all during pregnancy During labor, the longitudinal traction from the contracting uterus shortens the cervix so much that the cervix virtually disappears
Ideally, how should a woman birth experience be?
should be one that she was able to endure and allowed her self esteem to grow and the family bond to intensify as a shared experience
use light touch on woman abdomen while evaluating contractions or estimating strength manually because otherwise the uterine fundus can become...
tender if it has to push against the extra weight of a hand with each contraction, creating unnecessary discomfort for a woman in labor.
elongation of uterus can cause pressure against the diaphragm and causes the often expressed sensation that...
that a uterus is "taking control" of a woman's body.
caput succedaneum
the area of the fetal skull that contacts the cervix often becomes edematous from the continued pressure against it. This edema is called a caput succedaneum. in a newborn, the point of presentation can be analyzed from the location of the caput
3 parameters in assessing and interpreting FHR patterns
the baseline rate, variabilities in the baseline rate, and periodic changes in the rate (acceleration and deceleration)
fetal heart sounds best transmitted through the
the convex portion of a fetus because that is the part that lies in closest contact with the uterine wall.
good attitude brings the knees up to
the fetal abdomen
full descent
the fetal head protrudes beyond the dilated cervix and touches the posterior vaginal floor.
fourth stage comprises...
the first few hrs after birth
pressure should never be applied to...
the fundus of the uterus to effect birth because uterine rupture could occur.
contractions have 3 phases
the increment, when the intensity of the contraction increases; the acme, when the contraction is at its strongest; and the decrement, when the intensity decreases
woman is asked to keep pushing until
the occiput of the fetal head is firmly at the pubic arch.
some women seem to have additional pacemaker sites in other portions of the uterus and if this is so the contractions can be
uncoordinated Uncoordinated contractions may slow labor and can lead to failure to progress and fetal distress because they may not allow for adequate placental filling. All of these possibilities make evaluating the rate, intensity, and pattern of uterine contractions an important nursing responsibility.
cord is clamped with? why is cord blood taken?
two hemostats placed 8 to 10 in. from the infant's umbilicus A cord blood sample is often obtained to provide a ready source of infant blood if blood typing or other emergency measures, such as establishing whether fetal acidosis was present, needs to be done. Blood may also be taken for cord blood banking so the family has stem cells available if needed in the future.
A sufficiently mature fetus is ______ by continual variations of heart rate that occur with labor contractions
unaffected
in a bath birth the baby is born where?
underwater and then brought to surface for first breath 12 inches for bath to prevent a short umbilical cord from tearing
after full dilation of cervix, primary power is supplemented by...
use of a secondary power source, the ab muscles women should NOT bear down w ab muscles to push until the cervix is fully dilated... Doing so impedes the primary force and could cause fetal and cervical damage.
mark of Braxton hicks contractions
usually irregular and painful but do not cause cervical dilation
Labor is the series of events by which...
uterine contractions and abdominal pressure expel a fetus and placenta from the uterus
four types of cephalic position
vertex: ideal presenting part because the skull bones are capable of effectively molding to accommodate the cervix. This exact fit may actually aid in cervical dilatation as well as prevent complications such as a prolapsed cord brow face mentum
when is there little molding?
when the brow is the presenting part because the frontal bones are fused
child is considered born when...
whole body is born The newborn is immediately laid on the mother's naked abdomen and covered with a warmed blanket and cap to conserve heat and encourage mother-infant bonding
shape of fetal skull causes it to be wider in ______ than ________ (diameter)
wider in anteroposterior than transverse)
Urinary System
Pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Ask the birthing parent to void approximately every 2 hours during labor to avoid overfilling because overfilling can decrease postpartal bladder tone.
labor can be considerably extended if what positions?
ROP or LOP may be more painful for a woman because the rotation of the fetal head puts pressure on sacral nerves
2020 National Goals
Reduce the rate of maternal deaths to no more than 11.4 out of 100,000 live births from a baseline of 12.7 out of 100,000 live births. Reduce maternal illness due to pregnancy complications developed during hospitalized labor and delivery from a baseline of 31.1% to a target level of 28.0%. Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women from a baseline of 26.5% to a target of 23.9%. Reduce the rate of fetal deaths at 20 or more weeks gestation to no more than 5.6 out of 1,000 live births from a baseline of 6.2 out of 1,000. Reduce the rate of fetal and infant deaths during the perinatal period (28 weeks gestation to 7 days after birth) to no more than 5.9 out of 1,000 live births from a baseline of 6.6 out of 1,000 live births
In addition to prostaglandins, what can also help induce labor?
Rhythmical contractions brought on by a woman's orgasm can conceivably help as well, although again not until a uterus is prepared and ready for labor
Temperature regulation
Temperature may increase up to (1°F). Diaphoresis occurs with accompanying evaporation to cool and limit excessive warming. Monitor for any signs of infection. Offer cool washcloths for the patient's forehead for comfort if needed.
FHR and ultrasonic sensor or monitor
The FHR is monitored with the use of an ultrasonic sensor or monitor (see Fig. 15.16) also strapped against a woman's abdomen at the level of the fetal chest. The small Doppler unit converts fetal heart movements into audible beeping sounds and also records them on graph paper. If a woman changes her position (and she should change position often during labor), the sensor often needs to be repositioned. Remind a woman that the fetal heart signal may stop when she changes position so she does not think by the silence that her baby's heart has stopped beating. Urge women not to lie on their backs for monitoring but to rest on their side, sit in a chair, or bend forward over the foot of the bed or a birthing ball or rail so the likelihood of supine hypotension syndrome is not increased.
duration of contractions changes as labor progresses...
The duration of contractions also changes, increasing from 20 to 30 seconds at the beginning to a range of 60 to 70 seconds by the end of the first stage
4th step vag exam
The examiner places a hand on the outer edges of the woman's vulva and spread her labia while inspecting for lesions. Help look for red, irritated mucous membranes; open, ulcerated sores; and clustered, pinpoint vesicles. Presence of any lesions may indicate an infection and may possibly preclude vaginal birth.
how are pseudosinusoidal or false sinusoidal patterns viewed
These are usually transient, resolve spontaneously without intervention, and are associated with a good fetal outcome. The pattern may show some variability and perhaps an FHR acceleration. Identifying these is equally important so they can be differentiated from a true sinusoidal pattern. FHR baseline, variability, and patterns are categorized from 1 to 3 to help establish if a deviation is serious. Knowing these helps you to understand why interventions are initiated at certain points
the placenta has loosened and is ready to deliver when:
There is lengthening of the umbilical cord. A sudden gush of vaginal blood occurs. The placenta is visible at the vaginal opening. The uterus contracts and feels firm again.
0 station
When the presenting fetal part is at the level of the ischial spines (synonymous with engagement)
female circumcision
Women from cultures where female circumcision is allowed may have tightened or obstructed vaginal openings from scarring, which can make a vaginal exam painful. Note this because it also indicates a woman may need a cesarean birth to prevent perineal tearing if her vagina cannot dilate adequately.
no skull molding occurs when?
a fetus is breech because the buttocks, not the head, present first, also babies born by c section when there is no preprocedure labor also typically have no molding
Cutting the cord is part of the stimulus that initiates
a first breath or marks the newborn's most important transition into the outside world, the establishment of independent respirations.
Effective passage of a fetus through the birth canal involves not only position and presentation but also...
a number of different position changes in order to keep the smallest diameter of the fetal head (in cephalic presentations) always presenting to the smallest diameter of the pelvis. these positions are called CARDINAL MOVEMENTS OF LABOR
Prolapsed Cord
a portion of the cord passes between the presenting part and the cervix and enters the vagina before the fetus
in a primipara, non engagement of the head at the beginning of labor suggests that...
a possible complication such as an abnormal presentation or position, abnormality of fetal head, or cephalopelvic disproportion exists
periodic changes or fluctuations in FHR occur in response to contractions and fetal movements and are termed...
accelerations or decelerations Periodic changes are short-term changes in rate other than baseline; they last from a few seconds to 1 or 2 minutes.
third stage of labor
(placental stage) The third stage of labor, the placental stage, begins with the birth of the infant and ends with the delivery of the placenta. Two separate phases are involved: placental separation and placental expulsion.
Be certain to particularly monitor the length of the second stage of labor
(the average time is 1 hour; 2 hours is time for care providers to be alerted that a complication may be occurring)
concerns of baby that might lead to augmentation or intervention of labor further
-contractions greater than 70 seconds duration -pulse greater than 100 -fetal acidosis pH less than 7.2 -hyperactivity of fetus -meconium staining amniotic fluid -FHR >160 or <110 -full bladder in mom
what are the other factors that play a part in whether fetus is properly aligned in the pelvis and is in the best position to be born?
-fetal attitude -fetal lie -fetal presentation -fetal position
Whether a fetal skull can pass depends on...
-structure (bones, fontanelles and suture lines) -and alignment with pelvis
While a number of factors are known to be responsible for initiation of spontaneous labor, what are some main factors people believe cause spontaneous labor?
-withdrawal of progesterone -increase of prostaglandins -other biochemical markers
As a woman enters the active phase of the first stage, cervical dilation proceeds at a minimum of
1 cm/hr, or about 7 additional hours to reach full dilation (10 cm).
Anteroposterior diameter of pelvis
11 cm wide, is the narrowest diameter at the pelvic inlet
RR mom
18-20 dont count during contractions bc she breathes faster, same w BP because it rises 5-15 mmHg
At the end of the latent phase of the first stage of labor, cervical dilatation
3-4 cm
placenta is delivered how long after?
30 mins usually it weighs usually 1/6 of an infant
Labor usually begins between what weeks?
37-42 weeks of pregnancy, when a fetus is sufficiently mature to adapt to extrauterine life, yet not too large to cause mechanical difficulty with birth
O2 sat in normal fetus
40-70%
FHR decreases by how much during a contraction
5 beats/min, as soon as contraction strength reached 40 mmHg, although not measurable, FBP also rises
Checkpoint 15.3: Based on the previous study, which statement by Celeste would cause the most concern for the nurse that labor could be becoming traumatic for Celeste?
A) Im feeling as if im losing a grasp on things
Extension
As the occiput of the fetal head is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head extends, and the foremost parts of the head, the face and chin, are born.
encourage women to do what in active phase?
Encourage women to be active participants in labor by keeping active and assuming whatever position is most comfortable for them during this time, except flat on their back
what might encourage rotation from an occipitoposterior to an occipitoanterior position prior to and during labor?
Encouraging a woman to rest in a Sims position on the same side as the fetal spine or use a hands and knees position
category II
FHR factors are indeterminate Continue surveillance and reevaluation.
fetus is born fastest from
ROA or LOA position
second stage labor
The second stage, extending from the time of full dilatation until the infant is born
third stage of labor feelings
The third stage of labor is the time from the birth of the baby until the placenta is delivered. For most women, this is a time of great excitement because the infant has been born, but this can also be a time of feeling anticlimactic because the infant has finally arrived after being anticipated for so long a time.
catheter if woman needs it
The vulva is edematous from the pressure of the fetal presenting part, stretching the urethral canal downward and making the urethra difficult to locate. For best results, use a small catheter (No. 12 to 14F) and insert it between contractions.
What does labor represent?
a time of change as it is both an ending and a beginning for the woman, her fetus, and family
When should interventions be taken place in labor?
as much as possible they should be carried out between contractions so the woman can use a prepared childbirth technique to limit the discomfort of contractions.
massaging the perineum when?
as the fetal head enlarges the vaginal opening helps to keep it supple and prevent tearing to remove vaginal or rectal secretions and prepare the cleanest environment, the care provider may clean the perineum with a warmed antiseptic such as Iodaphor (cold solution causes cramping) and then rinse the area with sterile water.
nuchal cord must be removed before
baby is fully born
why do some women choose to have a cord blood sample withdrawn
banked for stem cells later on in life
if a woman had a perineal tear and needs suturing she will not likely feel it
because of the anesthesia
placental stage consists of
consists of both placental separation and expulsion. Observe for excessive bleeding during this time. Do not pull on the cord to hasten separation because this can lead to uterine inversion.
crowning
enlarges from size of a dime, to quarter, then half dollar
uterine contractions described
have rhythmicity, a progressive increase in length and intensity, and accompany dilatation of the cervix.
because the uterus may be so exhausted from labor that it cannot maintain contraction, there is a high risk for
hemorrhage (most dangerous time of birth for mother vs every 15 mins for first hour
what is the BEST presentation for birth?
when the fetus presents a biparietal diameter (narrowest fetal head diameter)
Partogram
where a woman progress in labor is recorded on a labor record Vital signs FHR Cervical dilation descent of fetal head urine tests drugs administered (note how much analgesia bc this can affect how long in labor)
diameters of fetal skull depend on what?
where the measurement is taken
Occipitofrontal diameter
widest anteroposterior diameter (13.5 cm) measured from posterior fontanelle to chin
psyche
woman's psychological outlook, refers to the psychological state or feelings a woman brings into labor. For many women, this is a feeling of apprehension or fright. For almost everyone, it includes a sense of excitement or awe.
severe edema suggests
hon of pregnancy a BP of 140/90 can confirm this
early decelerations
normally occur late in labor, when the head has descended fairly low; they are viewed as innocent. If they occur early in labor, before the head has fully descended, the head compression causing the waveform change could be the result of cephalopelvic disproportion and is a cause to investigate.
Active bleeding on the maternal surface of the placenta begins with
separation, which helps to separate the placenta still further by pushing it away from its attachment site. As separation is completed, the placenta sinks to the lower uterine segment or the upper vagina.
During a contraction, as the arteries of the uterus become sharply constricted, and the filling of cotyledons almost completely halts, the amount of nutrients, including oxygen, exchanged during this time is greatly reduced, causing a
slight but inconsequential fetal hypoxia
how long is labor?
takes place over a relatively short time frame (avg is 12 hrs)
The pulse and respiration rate should be measured and recorded at the same time intervals as
temp (q 4)
perineum LP AP TP
LP 30-60 min AP 30 min TP 15 min
freedman's curve
algorithm for determining normal labor progress,
to detect a full bladder?
palpate and percuss
how long can sterile surgical tools be left covered
up to 8 hrs
complete extension
(FACE) the back is arched and the neck is extended, presenting the occipitomental diameter of the head to the birth canal. This unusual position usually presents too wide a skull diameter to the birth canal for vaginal birth. Such a position may occur in an otherwise healthy fetus or may be an indication there is less than the usual amount of amniotic fluid present (oligohydramnios), which is not allowing the fetus adequate movement space. It also may reflect a neurologic abnormality in the fetus causing spasticity.
moderate flexion
(SINCIPUT) chin is not touching the chest but is in an alert or "military position." This position causes the next widest anteroposterior diameter, the occipitofrontal diameter, to present to the birth canal. A fair number of fetuses assume a military position early in labor. This does not usually interfere with labor, however, because later mechanisms of labor (descent and flexion) force the fetal head to fully flex.
good attitude
(VERTEX) complete flexion. The spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs (see Fig. 15.4A). This usual "fetal position" is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an ovoid shape, occupying the smallest space possible.
possible reasons why progesterone withdrawal begins...
-uterine muscle stretches from the increasing size of fetus, which results in release of prostaglandins -fetus presses on cervix, which stimulates release of oxytocin from posterior pituitary -oxy. stimulation works together with prostaglandins to initiate contractions -changes in range of estrogen to progesterone occurs, increasing estrogen in relation to progesterone which Is interpreted as progesterone withdrawal -placenta reaches set age which triggers contractions -rising fetal cortisol levels reduce progesterone formation and increase prostaglandin formation -fetal membrane produces prostaglandins, which stimulate contractions
Checkpoint 15.4: Celeste is anxious for her placenta to deliver so she can move to a rocking chair and help relieve her back pain. To best facilitate Celeste's wishes, which action is best?
.4 D. The nurse should assure her that a placenta loosens quickly so waiting time will not be long. Pulling on the cord, pushing on the uterine fundus, or hard pushing could all cause additional bleeding. The placenta must normally be delivered spontaneously.
A successful labor depends on 4 integrated concepts which are...?
1) Passage (a woman's pelvis) is of adequate size and contour 2) Passanger (fetus) is of appropriate size and in an advantageous position and presentation 3) Powers of labor (uterine factors) are adequate 4) Psyche (woman's psychological state which may either encourage or inhibit labor. this can be based on her past life experiences as well as her present psychological state.
Structure of cranium
8 bones -4 superior: -frontal (2 fused bones) -2 parietal -occipital (most important in childbirth) other four bones of skull (sphenoid, ethmoid, 2 temporal) lie at base of cranium and are of little significance
when is the head of a fetus prominent
8 cm across the vaginal opening
how to see if amniotic fluid in vagina
A sterile vaginal examination using a sterile speculum usually reveals whether amniotic fluid is present in the vagina. After vaginal secretions are obtained with a sterile, cotton-tipped applicator, test them with a strip of Nitrazine paper. Vaginal secretions are usually acid; amniotic fluid, in contrast, is alkaline. If amniotic fluid has passed through the vagina recently, the pH of the vaginal fluid will probably be alkaline (greater than 6.5) when tested by Nitrazine paper (appears blue-green or gray to deep blue). A false blue reading may occur in a woman with intact membranes who has a heavy, bloody show because blood is also alkaline. An additional test that can be done is a fern test (examination of vaginal secretions under a microscope). Because of its high estrogen content, amniotic fluid will show a fern pattern (see Chapter 5, Fig. 5.13A) when dried and examined in this way; urine will not.
Who else should be included in the labor process?
A support person as well as the woman in planning so the experience is a shared one
BP in stage 2 labor
A systolic pressure greater than 140 mmHg and a diastolic pressure greater than 90 mmHg, or an increase in the systolic pressure of more than 30 mmHg or in the diastolic pressure of more than 15 mmHg (the basic criteria for gestational hypertension), should be reported.
women using the bathroom in labor
A woman in labor is able to void most easily if she is allowed to use a bathroom. However, if a woman has ruptured membranes, check whether she should ambulate to a bathroom until it is confirmed the fetal head is well engaged so gravity does not cause a prolapsed cord. Use a bedpan or receptacle placed on a commode to collect any material passed from the vagina so this can be assessed as well.
second stage feeling
A woman typically feels contractions change from the characteristic crescendo-decrescendo pattern to an uncontrollable urge to push or bear down with each contraction as if to move her bowels. She may experience momentary nausea or vomiting because pressure is no longer exerted on her stomach as the fetus descends into the pelvis. She pushes with such force that she perspires and the blood vessels in her neck become distended.
Checkpoint 15.1: The nurse is collaborating with Celeste Bailey's obstetrician and is planning possible interventions in light of fetal position. Which of the following fetal positions is considered ideal and is most conducive to a birth that requires few interventions by the obstetrician?
A) The nurse is aware that an occipitoanterior position means the lie is cephalic—the back of the baby's head is facing the right anterior quadrant of the mother's pelvis. Full flexion means the smallest diameter of the fetal head is presenting to the cervix. This position is considered to be ideal and is most conducive to a healthy delivery that requires fewer interventions.
help with variable decelerations
As a first step, change the woman's position from supine to lateral if she is not already lying on her side. If a prolapsed cord is diagnosed as the cause of the variable decelerations, oxygen will be prescribed as well as changing her position to a knee-to-chest one to help relieve pressure on the cord. Because a prolapsed cord is a potential serious complication of labor,
Flexion
As descent is completed and the fetal head touches the pelvic floor, the head bends forward onto the chest, causing the smallest anteroposterior diameter (the suboccipitobregmatic diameter) to present to the birth canal. Flexion is also aided by abdominal muscle contraction during pushing.
when does the uterus contract down?
As the uterus contracts down on an almost empty interior, there is such a disproportion between the placenta and the contracting wall of the uterus that folding and separation of the placenta occur.
2nd step vag exam
Assemble equipment, including sterile examining gloves, sterile lubricant, and gauze squares. Ask the woman to turn onto her back with knees flexed (a dorsal recumbent position). Organization and planning improve efficiency. Positioning in this manner allows for good visualization of the perineum. Use of a sterile glove prevents contamination of the birth canal.
Checkpoint 15.6: The nurse assesses Celeste Bailey's uterine contractions and the FHR. Which of the following would the nurse document as a late deceleration?
B) The FHR decreased in rate 30 seconds after the start of a contraction. B. The nurse would document FHR decreasing in rate 30 seconds after the start of a contraction as a late deceleration. A late deceleration means the FHR decreases as a contraction ends, rather than at the beginning of a contraction, as is usual.
Checkpoint 15.5: Suppose Celeste is having long and hard uterine contractions. What length of contraction would the nurse report as indicative of a potential safety risk?
B) over 70 seconds
chief needs when arriving to a birthing center
Because the first stage of labor begins with the start of uterine contractions and takes hours to complete, most women have been having labor contractions for hours before they arrive at a birthing center or hospital. This means, most likely, that they have been experiencing pain and relying on their own or their partner's judgment that everything is going well for a long time. One of their chief needs when they arrive at a birthing setting, therefore, is reassurance their judgment has been correct—everything is going well and the exhaustion and increasing pain they feel is part of usual labor.
false contractions
Begin and remain irregular Felt first abdominally and remain confined to the abdomen and groin Often disappear with ambulation or sleep Do not increase in duration, frequency, or intensity Do not achieve cervical dilatation
true contractions
Begin irregularly but become regular and predictable Felt first in lower back and sweep around to the abdomen in a wave Continue no matter what the woman's level of activity Increase in duration, frequency, and intensity Achieve cervical dilatation
Smallest diameter of fetal skull
Biparietal diameter or transverse diameter (9.25 cm)
blood drawing
Blood is drawn for hemoglobin and hematocrit, a serologic test for syphilis (Venereal Disease Research Laboratory [VDRL] test), hepatitis B antibodies, and blood typing to determine whether a blood incompatibility is likely to exist in the newborn and what type of blood will need to be supplied if the woman should have an acute blood loss. If a woman gives permission for HIV testing, blood for this will be drawn as well.
GI System
Blood shunts to life-sustaining organs causing the GI system to become fairly inactive during labor. Digestive and emptying time of the stomach becomes lengthened. Some women experience a loose bowel movement as contractions grow strong. Although many hospital protocols dictate that women who present in labor should not partake of oral nutrition, there is little evidence to support this restrictive practice.
CV system
Cardiac output increases 40%-50% from prelabor levels. Blood loss at birth is 300-500 ml on average. Blood pressure may rise with pain response and, due to work of the system during contractions, by an average systolic rise of 15 mmHg per contraction. Epidural anesthesia may cause hypotension. Monitor closely for hemorrhage. Monitor for signs of pathology with hypertensive episodes. Ensure that patients are well hydrated prior to epidural administration. This usually involves an IV fluid bolus (see
Checkpoint 15.2: Celeste Bailey didn't recognize for over an hour that she was in labor. During her prenatal education, Celeste should have been taught to recognize which sign of true labor?
D) "Show" or release of cervical mucus plug
decelerations
Decelerations are visually apparent, usually symmetrical, periodic decreases in FHR resulting from pressure on the fetal head during contractions as parasympathetic stimulation in response to vagal nerve compression brings about a slowing of FHR. Early deceleration follows the pattern of the contraction, beginning when the contraction begins and ending when the contraction ends. However, the waveform of the FHR change is the inverse of the contraction waveform, or the lowest point of the deceleration occurs with the peak of the contraction (a mirror image of the contraction). The rate rarely falls below 100 beats/min, and it returns quickly to between 110 and 160 beats/min at the end of the contraction
20 mins external contraction monitor and then intermittently by doppler...
Depending on the hospital or birthing center policy, most women are monitored by an external contraction monitor for about 20 minutes in early labor. The monitor is then removed, and contractions are assessed intermittently by Doppler because extensive electronic monitoring has not shown to lower fetal mortality with low-risk women, can limit mobility, and can lead to an increase in cesarean birth (Cox & King, 2015). The use of internal fetal monitoring is reserved for high-risk pregnancies and is described in Chapter 24.
4 methods can be used to determine if the fetus is in an optimal position for birth
Determining the place on the woman's abdomen where fetal heart tones are heard strongest Abdominal inspection and palpation, called Leopold maneuvers Vaginal examination Sonography
3rd step vag exam
Discard one drop of clean lubricating solution and drop an ample supply on tips of gloved fingers of examiner. Discarding the first drop of lubricant ensures quantity used will not be contaminated.
step 11 vag exam
Document procedure, assessment findings, and how patient tolerated procedure. Documentation provides a means for communication and evaluation of care and patient outcomes.
Internal Rotation
During descent, the biparietal diameter of the fetal skull was aligned to fit through the anteroposterior diameter of the mother's pelvis. As the head flexes at the end of descent, the occiput rotates so the head is brought into the best relationship to the outlet of the pelvis, or the anteroposterior diameter is now in the anteroposterior plane of the pelvis. This movement brings the shoulders, coming next, into the optimal position to enter the inlet, or puts the widest diameter of the shoulders (a transverse one) in line with the wide transverse diameter of the inlet.
Hematopoietic system
During labor, WBCs increase to a level of 25,000-30,000 cells/mm3 compared to 5,000-10,000 cell/mm3. Continue to monitor for any signs of infection.
Musculoskeletal System
During pregnancy, relaxin is secreted from the ovaries causing the cartilage between joints to be more flexible. This allows the joints of the pelvis to be able to open as much as 2 cm in labor to allow for fetal passage. Monitor for appropriate mobility and be mindful of fall risks.
active phase
During the active phase of labor, cervical dilatation occurs more rapidly. Contractions grow stronger, lasting 40 to 60 seconds, and occur approximately every 3 to 5 minutes. Bloody Show (increased vaginal secretions) and perhaps spontaneous rupture of the membranes may occur during this time. This phase can be difficult for a woman because contractions grow so much stronger and last so much longer than they did in the latent phase that she begins to experience true discomfort. It is also both an exciting and a frightening time because it is obvious something dramatic is definitely happening.
During latent phase have women do what
During this phase, encourage women to continue to walk about and make preparations for birth, such as doing last-minute packing for her stay at the hospital or birthing center, preparing older children for her departure and the upcoming birth, or giving instructions to the person who will take care of them while she is away. If desired, she could begin alternative methods of pain relief such as aromatherapy, distraction, or acupressure
in multiparae, dilation may proceed before effacement is complete. effacement must occur by...
Effacement must occur by the end of dilatation, however, before the fetus can be safely pushed through the cervical canal; otherwise, cervical tearing can result.
initial electronic monitoring
Electronic monitoring is noninvasive, easily applied, and does not require cervical dilatation or fetal descent before it can be used, so it can be introduced at any time during labor. The presence and duration of uterine contractions is gained by means of a pressure transducer or tocodynamometer (toko is Greek for "contraction") strapped to the woman's abdomen or held in place by stockinette (Fig. 15.16).
assessment of pelvic adequacy
Evaluating pelvic adequacy using internal conjugate and ischial tuberosity diameters is generally done during pregnancy either manually or by sonogram, so, by weeks 32 to 36 of pregnancy, a primary care provider can be alerted that cephalopelvic disproportion could occur. Because the diameters obtained during pregnancy have not changed, they are not retaken if already obtained.
postpartum fever
Examine her teeth for caries or abscesses because an oral infection might account for a postpartal fever.
herpes?
Examine the outer and inner surfaces of her lips carefully to detect herpes lesions (pinpoint vesicles on an erythematous base)
1st step Leopold
Explain the procedure and instruct the woman to void to empty her bladder. Explanation reduces anxiety and enhances cooperation. An empty bladder promotes comfort and allows for more productive palpation because fetal contour will not be obscured by a distended bladder.
a fetus is subjected to extreme pressure by uterine contractions and passage through the birth canal, so it is important to ascertain that the _____remains within normal limits despite these pressures.
FHR
Category I
FHR factors (baseline and variability are normal) continue monitoring, no action needed
category III
FHR tracings are abnormal Prompt evaluation is required. Expedite action to determine the cause and resolve the situation is required. This may include but is not limited to provision of maternal oxygen, change in maternal position, discontinuation of labor stimulation, treatment of maternal hypotension, and treatment of tachysystole with FHR changes. If category III tracing does not resolve with these measures, birth should be undertaken.
FHR variability
FHR variability or the difference between the highest and lowest heart rates shown on a strip is one of the most reliable indicators of fetal well-being. Variability is reflected on an FHR tracing as a slight irregularity or "jitter" to the wave. The degree of baseline variability increases (5 to 15 beats/min) when a fetus moves; it slows if a fetus sleeps. If no variability is present, it indicates the natural pacemaker activity of the fetal heart (effects of the sympathetic and parasympathetic nervous systems) may be affected. This may occur as a response to narcotics or barbiturates administered to a woman in labor, but the possibility of fetal hypoxia and acidosis must also be considered and investigated. very immature fetuses show diminished baseline variability because of a reduced nervous system response to stimulation and immature cardiac node function
step 6 Leopold
Face the woman, hold the left hand stationary on the left side of the uterus while you palpate with the right hand on the opposite side of the uterus from top to bottom. Repeat palpation using the opposite side. This maneuver locates the back of the fetus. The fetal back feels like a smooth, hard, and resistant surface; the knees and elbows of the fetus on the opposite side feel more like a number of angular bumps or nodules.
A woman in labor Is not aware of verbal and non verbal expressions around her? true or false?
False! They are extremely aware so assessments must be done quickly and thoroughly so they do not lose patience
Fetal Presentation is? Determined by what factors?
Fetal presentation denotes the body part that will first contact the cervix or be born first fetal lie degree of fetal flexion (attitude)
Step 5 Leopold
First maneuver: Stand at the foot of the woman, facing her, and place both hands flat on her abdomen. Palpate the superior surface of the fundus. Determine consistency, shape, and mobility. This maneuver determines whether the fetal head or breech is in the fundus. A head feels more firm than a breech, is round and hard, and moves independently of the body (the breech feels softer and moves only in conjunction with the body).
lower round bulge d/t full bladder is a danger sign for two reasons:
First, the bladder may be injured by the pressure of the fetal head pressing against it; and second, the pressure of the full bladder may not allow the fetal head to descend. To avoid a full bladder, ask women to try to void about every 2 hours during labor.
Step 8 Leopold
Fourth maneuver: Place fingers on both sides of the uterus approximately 2 in. above the inguinal ligaments, pressing downward and inward in the direction of the birth canal. Allow fingers to be carried downward. This maneuver is only done if the fetus is in a cephalic presentation because it determines fetal attitude and degree of fetal extension into the pelvis. The fingers of one hand will slide along the uterine contour and meet no obstruction, indicating the back of the fetal neck. The other hand will meet an obstruction an inch or so above the ligament—this is the fetal brow. The position of the fetal brow should correspond to the side of the uterus that contained the elbows and knees of the fetus. If the fetus is in a poor attitude, the examining fingers will meet an obstruction on the same side as the fetal back; that is, the fingers will touch the hyperextended head. If the brow is very easily palpated (as if it lies just under the skin), the fetus is probably in a posterior position (the occiput is pointing toward the woman's back).
important things to ask mom upon admission (long list)
Her baby's expected date of birth (EDB) When her contractions began Amount and character of any show Whether rupture of membranes has occurred Any known drug allergies If she uses any recreational or prescription drugs (women addicted to opioids need special precautions before analgesia is administered for pain management; their newborn may need special care to prevent neonatal abstinence syndrome from opioid withdrawal) Past pregnancy and present pregnancy history if her prenatal record is not available. It is important to note the route of delivery with any prior births as well as any complications which may have occurred. Her birth plan or what individualized measures she thinks will create a memorable experience for her such as whether she wants analgesia or who she would like to cut the umbilical cord Assess the following: Vital signs: temperature, pulse, respirations, and blood pressure (assess between contractions for comfort and accuracy) Nature of her contractions (frequency, duration, and intensity) Her rating of pain on a 10-point scale What she has done to be prepared for labor such as learning breathing exercises Urine specimen for protein and glucose Position and presentation of her fetus
where heart sound best heard
In a vertex or breech presentation, fetal heart sounds are usually best heard through the fetal back. In a face presentation, the back becomes concave so the sounds are best heard through the more convex thorax. In breech presentations, fetal heart sounds are heard most clearly high in the uterus, at a woman's umbilicus or above. In cephalic presentations, they are heard loudest low in a woman's abdomen. In an ROA position, sounds are heard best in the right lower quadrant. In an LOA position, sounds are heard best in the left lower quadrant. In posterior positions (LOP or ROP), heart sounds may be loudest at a woman's side.
External Rotation
In external rotation, almost immediately after the head of the infant is born, the head rotates a final time (from the anteroposterior position it assumed to enter the outlet) back to the diagonal or transverse position of the early part of labor. This brings the after coming shoulders into an anteroposterior position, which is best for entering the outlet. The anterior shoulder is born first, assisted perhaps by downward flexion of the infant's head.
Which anteroposterior diameter that presents to the birth canal is determined not only by rotation but also by the degree of flexion of the fetal head?
In full flexion, the fetal head flexes so sharply that the chin rests on the chest, and the smallest anteroposterior diameter, the suboccipitobregmatic, presents to the birth canal. If the head is held in moderate flexion, the occipitofrontal diameter presents. In poor flexion (the head is hyperextended), the largest diameter (the occipitomental) will present.
Neuro and Sensory response
Increased pain Increased respiratory rate Where pain registers is important in appreciating why epidural anesthesia is effective. For early labor, the anesthetic block needs to suppress the lower thoracic synapses; for birth, it needs to block sacral nerves. Discuss nonpharmacologic pain techniques if the patient does not desire medication.
Respiratory system
Increased respiratory rate to respond to increased cardiovascular parameters Total oxygen needs increase 100% during the second stage of labor. Monitor for any signs of hyperventilation. If hyperventilation occurs, rebreathing into a paper bag can be helpful. If needed, use appropriately patterned breathing to regulate respiratory rate.
Fluid Balance
Insensible water loss increases during labor due to diaphoresis and the increase in rate and depth of respirations. Encourage women to sip fluid during labor the same as they would if they were exercising to keep hydrated. If a woman is nauseated by labor, encourage sips of fluid, ice chips, or hard candy to supply some extra fluid.
looking for anemia?
Inspect the mucous membrane of her mouth and the conjunctiva of her eyes for color to see if paleness suggests anemia.
check fetal presentation why?
It is important to document fetal presentation and position at the beginning of labor because these help predict if the presentation of a body part other than the vertex could be putting a fetus at risk or leading to the possibility labor will be longer than usual because fetal descent will be less effective, causing ineffective dilatation of the cervix. A different presentation could also lead to early rupture of membranes, increasing the possibility of infection, fetal anoxia from cord prolapse, and meconium staining, all of which can lead to cesarean birth or respiratory distress at birth
placenta inspection
It needs to be inspected after delivery to be certain it is intact and part of it was not retained (which could prevent the uterus from fully contracting and lead to postpartal hemorrhage).
second stage of labor what woman is thinking
It takes a few contractions of this new type for a woman to realize everything is all right, just different, and to appreciate it feels better and less frightening, to push with contractions. As she concentrates on pushing, she may become unaware of the conversation in the room. Pain may disappear as all of her energy and thoughts are directed toward giving birth.
variable decelerations tend to occur more frequently after
It tends to occur more frequently after rupture of the membranes than when membranes are intact, or with oligohydramnios (the presence of less than a normal amount of amniotic fluid), such as occurs in postterm pregnancy or with intrauterine growth restriction.
examples of possible fetal positions, dont need to memorize just be familiar with
LOA, left occipitoanterior LOP, left occipitoposterior LOT, left occipitotransverse ROA, right occipitoanterior ROP, right occipitoposterior ROT, right occipitotransverse LSaA, left sacroanterior LSaP, left sacroposterior LSaT, left sacrotransverse RSaA, right sacroanterior RSaP, right sacroposterior RSaT, right sacrotransverse LAA, left scapuloanterior LAP, left scapuloposterior RAA, right scapuloanterior RAP, right scapuloposterior
Contractions LP AP TP
LP 30-60 min AP: 150-30 mins TP 10-15 mins
FHR LP, AP, TP
LP: 30-60 mins AP: 15-30 min TP: 15-30 min As a rule, determine the FHR every 30 minutes during beginning latent labor, every 15 minutes during active first stage labor, and every 5 minutes during the second stage of labor.
ambulation and change of position and support LP AP TP
LP: Continuously; question if membranes rupture AP: same ^ TP: continuously support is continuous always
voiding LP, AP, TP
LP: q 2 hrs for all
pulse, resp, BP,(LP, AP, TP)
LP: q 30-60 mins AP: q 30-60 TP: q15-30 min
temp (in Latent phase, then active phase, then transition phase)
LP: q4 AP: q4 TP: q4 all are unless membranes are ruptured and then q 2
Psychological Response
Labor can lead to emotional distress because it is not only painful and fatiguing but it also represents the beginning of a major life change for a woman and her partner. Offer expeditious care to the patient. Continue to encourage her process of labor. Prior to birth, a woman can investigate the services of a doula. A doula is an individual with specialized training who provides physical, emotional, and psychological support to laboring parents. A doula does not perform clinical tasks. However, the simple gift of presence has been shown to reduce the need for analgesia and anesthesia requests, shorten labor times, and increase satisfaction with the birth experience.
oscilloscope screen and what to read on it
Labor monitors trace both the FHR and the duration and interval of uterine contractions onto an oscilloscope screen and produce a permanent record on paper rolls Uterine contraction information is recorded on the bottom half of the paper, whereas FHR is recorded on the top half. Time can be calculated by counting the number of bold vertical lines on the paper (the space between two bold lines represents 60 seconds).
6 concepts that Make labor and birth as natural as possible
Labor should begin on its own, not be artificially induced. Women should be able to move about freely throughout labor, not be confined to bed. Women should receive continuous support from a caring support person during labor. No interventions such as intravenous fluid should be used routinely. Women should be allowed to assume a nonsupine position such as upright and side lying for birth. Mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding
late decelerations
Late decelerations are those in which the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively (Fig. 15.19). This is an ominous pattern in labor because it suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during uterine contractions. This pattern may occur with marked hypertonia or increased uterine tone. Immediately change the woman's position from supine if she is lying down to lateral to relieve pressure on the vena cava and supply more blood to the uterus and fetus. Intravenous fluid or oxygen may be prescribed. Prepare for a prompt cesarean birth of the infant if the late decelerations persist or if FHR variability becomes abnormal (absent or decreased).
7th step vag exam
The examiner touches the cervix with gloved fingers to assess: Cervical consistency, position, and rate if firm or soft. Extent of dilatation and whether an anterior rim or lip of cervix is present. Estimate the degree of effacement. Estimate whether membranes are intact. The cervix feels like a circular rim of tissue around a center depression. If firm, it feels similar to the tip of a nose; if soft, it is as pliable as an earlobe. An index finger averages about 1 cm; a middle finger about 1.5 cm. If they can both enter the cervix, the cervix is dilated 2.5-3 cm. If there would be room for double the width of two fingers, the dilatation is about 5-6 cm. When the space is four times the width of two fingertips, dilatation is complete at 10 cm. Effacement is estimated in a percentage depending on thickness. A cervix before labor is 2-2.5 cm thick. If it is only 1 cm thick, it is 50% effaced. If it is tissue paper thin, it is 100% effaced. With a 100% effaced cervix, dilatation is difficult to feel because the edges of the cervix are so thin. The membranes (with a slight amount of amniotic fluid in front of the presenting part) assume the shape of a watch crystal. With a contraction, they bulge forward, become prominent, and can be felt much more readily.
the fetus in the second stage of labor
The fetus begins descent and, as the fetal head touches the internal perineum to begin internal rotation, her perineum begins to bulge and appear tense. The anus may become everted, and stool may be expelled. As the fetal head pushes against the vaginal introitus, this opens and the fetal scalp appears at the opening to the vagina and enlarges from the size of a dime, to a quarter, then a half-dollar. This is termed crowning.
fourth stage labor (sometimes)
The first 1 to 4 hours after birth of the placenta is sometimes termed the "fourth stage" to emphasize the importance of close maternal observation needed at this time.
first stage labor
The first stage of dilatation, which begins with the initiation of true labor contractions and ends when the cervix is fully dilated 12 hrs three segments: a latent, an active, and a transition phase
cervical dilation form "alert line"
The form shows an "alert" line, which marks when 4 hours has passed. Four hours beyond that, an "action" line advises a primary care provider that cervical dilation is taking longer than usual and that an intervention may be necessary to make the labor safe and effective. nursing responsibilities to let someone know when one of these lines is approaching.
position is indicated by an abbreviation of 3 letters...
The middle letter denotes the fetal landmark (O for occiput, M for mentum, Sa for sacrum, and A for acromion process). The first letter defines whether the landmark is pointing to the mother's right (R) or left (L). The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T). example: If the occiput of a fetus points to the left anterior quadrant in a vertex position, for example, this is a left occipitoanterior (LOA) position. If the occiput points to the right posterior quadrant, the position is right occipitoposterior (ROP).
variable decelerations
The pattern of variable decelerations refers to decelerations that occur at unpredictable times in relation to contractions. They may indicate compression of the cord, which can be an ominous development in terms of fetal well-being (Fig. 15.20). Cord compression may be occurring because of a prolapsed cord, but it most often occurs because the fetus is simply lying on the cord.
Step 7 Leopold
Third maneuver: Gently grasp the lower portion of the abdomen just above the symphysis pubis between the thumb and fingers and try to press the thumb and finger together. Determine any movement and whether the part feels firm or soft. This maneuver determines which part of the fetus is at the inlet and its mobility. If the presenting part moves upward so your fingers and thumb can be pressed together, the presenting part is not engaged (not firmly settled into the pelvis). If the part is firm, it is the head; if soft, then it is the breech.
how can assessing FHR be done
This can be done by inspecting an FHR monitoring strip or by periodic auscultation by a fetoscope (a modified stethoscope attached to a headpiece), a Pinard stethoscope (a hollow tube that directs sound into the ear), or a Doppler unit (which uses ultrasound waves that bounce off the fetal heart to produce echoes or clicking noises, which reflect the fetal heartbeat [Fig. 15.15]) as labor progresses.
powers of labor
This is the force supplied by the fundus of the uterus and implemented by uterine contractions, which causes cervical dilatation and then expulsion of the fetus from the uterus
why might the shoulder presentation happen?
This presentation may be caused by pelvic contractions, in which the horizontal space is greater than the vertical space or by the presence of a placenta previa (the placenta is located low in the uterus, obscuring some of the vertical space). It also can be caused by relaxed abdominal walls from grand multiparity, which allow the unsupported uterus to fall forward
duncan presentation can take how long?
This stage can take anywhere from 1 to 30 minutes and still be considered normal. Because bleeding occurs as the placenta separates, before the uterus contracts sufficiently to seal maternal capillaries, there is a blood loss of about 300 to 500 ml, not a great amount in relation to the extra blood volume that was formed during pregnancy.
step 10 vag exam
Upon withdrawal of the examining hand, help wipe the perineum front to back to remove secretions or examining lubricant. Help patient return to side or sit up. Wiping front to back prevents moving rectal contamination forward to the vagina. Side lying or sitting helps prevent supine hypotension syndrome.
Inertia
Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion (inertia). This problem may be correctable but needs augmentation or other interventions to accomplish this.
1st step vag exam
Wash your hands and explain the procedure to the patient. Provide privacy. Hand washing helps prevent the spread of microorganisms. Explanations ensure patient cooperation and compliance. Privacy enhances self-esteem.
Step 2 Leopold
Wash your hands using warm water. Provide privacy. Hand washing prevents the spread of possible infection. Using warm water aids in patient comfort and prevents tightening of abdominal muscles during palpation.
delaying cutting of cord helps ensure cord clamping??
adequate red blood cell and white cell count in the newborn The timing of cord clamping, however, is individualized because late clamping of the cord this way could cause overinfusion with placental blood and the possibility of polycythemia and hyperbilirubinemia in a susceptible newborn, a particular concern if the infant is preterm.
as dilation begins, increase in what?
amount of vaginal secretions (show) because minute capillaries in the cervix rupture and the last of the mucus plug that has sealed the cervix since early pregnancy is released.
if a fetus does not rotate, leaving the anteroposterior diameter of the skull presenting to the transverse diameter of the outlet...
an arrest of progress may occur
The exact reason why labor begins is unknown. It most likely occurs because of
an interplay between fetal and uterine factors that registers as progesterone withdrawal.
As labor contractions progress and become regular and strong, the uterus gradually differentiates itself into two distinct functioning areas:
an upper portion, which thickens, and a lower segment, which becomes thin-walled, supple, and passive so the fetus can be pushed out of the uterus easily.
baseline FHR
analyzing the pace of fetal heartbeats recorded in a minimum of 2 minutes obtained between contractions. A normal rate is 110 to 160 beats/min.
poor attitude means the knees...
and the legs are extended
Leopold maneuvers
are a systematic method of observation and palpation to determine fetal presentation and position and are done as part of a physical examination.
Nonperiodic accelerations
are temporary normal increases in FHR caused by fetal movement, a change in maternal position, or administration of an analgesic. An acceleration is a visually apparent abrupt increase (onset to peak in less than 30 seconds) in the FHR. At 32 weeks of gestation and beyond, an acceleration has a peak of 15 beats/min or more above baseline with a duration of 15 seconds or more but less than 2 minutes from onset to return. Before 32 weeks of gestation, an acceleration has a peak of 10 beats/min or more above baseline, with a duration of 10 seconds or more but less than 2 minutes from onset to return. Prolonged acceleration lasts 2 minutes or more but less than 10 minutes in duration. If an acceleration lasts 10 minutes or longer, it is a baseline change or a new baseline is established.
In primipras, effacement is accomplished when?
before dilatation begins. Be sure to inform women of both effacement and dilation following a pelvic examination. ex: If a woman is told at noon, for example, she is 3 cm dilated and then at 4 PM, she is told she is still 3 cm dilated, it is a discouraging report because it seems as if absolutely nothing has happened in 4 hours. Effacement, however, will have been occurring; telling her about this can be the encouragement she needs to continue breathing or working with contractions.
latent phase
begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins. Contractions during this phase are mild and short, lasting 20 to 40 seconds. Cervical effacement occurs, and the cervix dilates minimally. A woman who enters labor with a "nonripe" cervix will probably have a longer than average latent phase. If a woman wants analgesia at this point, she shouldn't be denied of it, but analgesia given too early in labor is a factor that tends to prolong this phase. A birthing parent who is multiparous usually progresses more quickly than a nullipara.
partial extension presents the _____ of the head to the birth canal
brow
how can a fetus get an O2 sat
catheter inserted next to the cheek
Longitudinal lies are further classified as...
cephalic, which means the fetal head will be the first part to contact the cervix, or breech, with a foot or the butt as the first portion to contact the cervix
after each cervical exam, what are two things that are plotted on a graph?
cervical dilation (S-shaped curve) fetal descent ("moulding")
in a face presentation, what is the chosen point?
chin (mentum (M))
is mom hot or cold after birth?
cold 10-15 mins
type 1 vs type 2 herpes
common cold sores (don't kiss baby) vs genital herpes (can be lethal to newborns)
transition phase
contractions reach their peak of intensity, occurring every 2 to 3 minutes with a duration of 60 to 70 seconds, and a maximum cervical dilatation of 8 to 10 cm occurs. If it has not previously occurred, show will occur as the last of the mucus plug from the cervix is released. If the membranes have not previously ruptured, they will usually rupture at full dilatation (10 cm). By the end of this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred.
The person a woman chooses to stay with her during childbirth is often ___________ determined...
culturally determined; varies from being a husband, significant other, partner, father, of child, sister, parent, close friend
prolonged decelerations
decelerations that are a decrease from the FHR baseline of 15 beats/min or more and last longer than 2 to 3 minutes but less than 10 minutes. They generally reflect an isolated occurrence, but they may signify a significant event, such as cord compression or maternal hypotension. For this reason, they must be reported and documented. If a deceleration lasts longer than 10 minutes, it is considered a baseline change.
as labor progresses, relaxation intervals...
decrease from 10 minutes early in labor to only 2 to 3 minutes.
cardinal movements of labor
descent flexion internal/external rotation extension expulsion
attitude
describes the degree of flexion during labor or the relation of fetal parts to each other
obtaining info when she first gets to the hospital
description of her labor thus far, her general physical condition, and her preparedness and plans for labor and birth. This amount of information is scant but helps to establish whether the woman is in active labor and needs immediate preparation for birth or whether she has arrived at the birthing setting at an early stage of labor and therefore will benefit most from paced interventions.
palpate for lymph nodes to
detect the possibility of a respiratory infection.
a presenting part that is descending but has not yet reached the ischial spines may be referred to as
dipping
during transition phase a woman should feel...
discomfort that is so strong, it might be accompanied by nausea and vomiting. She may also experience a feeling of loss of control, anxiety, panic, and/or irritability. Because of the intensity and duration of the contractions, it may seem as though labor has taken charge of her. A few minutes before, she may have enjoyed having her forehead wiped with a cool cloth or her back rubbed. Now, she may knock a partner's hand away from her.
who does a vag exam, when are they best done
doctor or nurse specialized best done between contractions kept to a minimum to prevent infections
why should pressure never be applied in a contracted state?
doing so could cause the uterus to evert (turn inside out), accompanied by massive hemorrhage (Bienstock et al., 2015).
descent
downward movement of the biparietal diameter of the fetal head within the pelvic inlet.
during labor, the area of the fetal skull that contacts the cervix often becomes...
edematous from the continued pressure against it. this edema is called a caput succedaneum
Even more marked than the changes in the body of the uterus are two changes that occur in the cervix:
effacement and dilation you can be 100% effaced-cervical canal thinned but only 4 cm dilated
if a fetus presents one of the anteroposterior diameters of the skull to the anteroposterior diameter of the inlet...
engagement, or the settling of the fetal head into the pelvis may not occur
Dilation
enlargement or widening of the cervical canal from an opening a few millimeters wide to one large enough (approximately 10 cm) to permit passage of a fetus
dilation occurs because
first because uterine contractions gradually increase the diameter of the cervical canal lumen by pulling the cervix up over the presenting part of the fetus. Secondly, the fluid-filled membranes push ahead of the fetus and serve as an opening wedge. If they are ruptured, the presenting part will serve this same function, although maybe not as effectively.
fourth stage of labor
first few hrs after birth. it signals the beginning of dramatic changes because it marks the beginning of both a new life and new family
woman without anesthesia feels what as birth of the head
flash of pain or burning sensation almost like poured hot water right after baby head check for umbilical cord!!!!!!!!!!
a presenting part that is not engaged is
floating
Palpating for ________ spaces during a pelvic examination helps to establish what?
fontanelle spaces can help establish position of fetal head and whether it is in a favorable position for birth (fontanelle spaces compress to aid in molding of fetal head, can be assessed manually through cervix after cervix has dilated)
contractions are assessed according to what?
frequency duration strength
how does the contour of the overall uterus change?
from a round, ovoid structure to an elongated one with a vertical diameter markedly greater than the horizontal diameter. This lengthening straightens the body of the fetus, bringing it into better alignment with the cervix and pelvis.
second stage of labor time span
from full dilatation and cervical effacement to birth of the infant.
crede maneuver
gentle pressure down on contracted uterine fundus by HCP
perineal tears are graded how?
graded 1-4, 1 being least severe, 4 extending to and including the rectum
in a transverse lie a fetus lies... presenting part? moms abdomen?
horizontally in the pelvis so the longest fetal axis is perpendicular to that of the mother the presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand or elbow the usual contour of the moms abdomen at term may appear fuller side to side rather than top to bottom only 1% of fetus'
most infants in a transverse line must be born by cesarean birth... however...
however, because they can neither be turned nor born vaginally due to this "wedged" position.
if the woman is active in labor, the hx taken on arrival might be the only...
hx obtained until after the baby is born
piton causes...so check...
hypertension by vasoconstriction so be certain to obtain a baseline blood pressure measurement before administration
lying longer than an hour in lithotomy position can lead to
intense pelvic congestion and possibly thrombophlebitis. also lying flat could slow down the process of birth as well
effective labor depends on
interactions between the passage, the passenger, the power of contractions, and a woman's psychological readiness.
pushing is considered
involuntary-even if she wants to she might not be able to stop
in some women, contractions appear to originate in
lower uterine segment rather than in the fundus These are reversed and ineffective and may actually cause tightening rather than dilatation of the cervix. It is difficult to tell from palpation that contractions are being initiated in a reverse pattern. It can be suspected, however, if the woman tells you she feels pain in her lower abdomen before the contraction is readily palpated at the fundus. It is truly revealed only when apparently strong uterine contractions do not cause cervical dilatation.
after placenta inspection, if moms uterus has not contracted firmly on its own, PCP will...
massage fundus to urge it to contract also Oxytocin (Pitocin 10 units) may be prescribed to be administered intramuscularly (IM) or per 1,000 ml fluid intravenously (IV) to also help contraction (Karch, 2013). If excessive bleeding with poor uterine contraction remains, an injection of carboprost tromethamine (Hemabate) or methylergonovine maleate (Methergine) is yet another solution to increase uterine contraction and to guard against hemorrhage. It is important to know prior to the second stage whether a woman has a contraindication to either of these drugs such as asthma or hypertension. administration of these drugs is a NU responsibility in most places
at the outlet, the fetus must rotate to present this narrowest fetal head diameter (biparietal) to the...
maternal transverse diameter, again also 11 cm wide
pulse and respirations after birth
may be fairly rapid immediately after birth (80 to 90 beats/min and 20 to 24 breaths/min)
nuchal cord and pushing
may be necessary to prevent a woman from pushing immediately after delivery of fetal head ask woman to pant with contractions
in early labor, utter-tubal pacemaker...
may not operate in a synchronous manner. This makes contractions sometimes strong, sometimes weak, and somewhat irregular. This mild incoordination of early labor improves after a few hours as the pacemaker becomes more attuned to calcium concentrations in the myometrium and begins to function effectively.
multiparae engagement? how is degree of engagement established?
may or may not be present at the beginning of labor. degree of engagement is established by a vaginal and cervical examination
Integumentary system: the pressure involved in the birth process is often reflected in...
minimal petechiae or ecchymotic areas on a fetus (particularly presenting part). also may be edema of the presenting part (caput succedaneum) from this pressure
Cephalic Presentation
most frequent type (96%) Fetal head is the body that contacts the cervix
meconium staining
not always a sign of fetal distress but is usually correlated reveals the fetus has had a loss of rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. Although meconium staining may be usual in a breech presentation because pressure on the buttocks causes meconium loss, it should always be reported immediately even with breech presentations so its cause can be investigated.
in a vertex position, what is the chosen point?
occiput (O)
descent occurs because
of pressure on the fetus by the uterine fundus As the pressure of the fetal head presses on the sacral nerves at the pelvic floor, the mother will experience the typical "pushing sensation," which occurs with labor. As a woman contracts her abdominal muscles with pushing, this aids descent.
first stage lasts from
onset of cervical dilation until dilation is complete (10 cm)
which sutures can be easily palpated on the newborn skull?
overlapping of sagittal suture line and generally coronal suture line
molding
overlapping of skull bones along suture lines, which causes a change in the shape of the fetal skull to one long and narrow, a shape that facilitates passage through the rigid pelvis
like cardiac contractions, labor contractions begin at a ... point
pacemaker point located in the uterine myometrium near one of the uterotubal junctions. Each contraction begins at that point and then sweeps down over the uterus as a wave. After a short rest period, another contraction is initiated and the downward sweep begins again.
timing of cord clamping depends on
parents preference and maturity of the infant umbilical cord continues to pulsate for a few minutes after birth and then the pulsation ceases delaying cutting until pulsing ceases allows as much as 100 mL more of blood to pass from placenta to fetus
technique to help fetus achieve extension and allow the smallest head diameter to present is for the care provider to...
place a sterile towel over the rectum and press forward on the fetal chin while the other hand presses downward on the occiput (Ritgen maneuver) this maneuver is often unnecessary because babies tend to be born easily without this assistance
+3 or +4 stations
presenting part is at the perineum and can be seen if the vulva is separated (i.e., it is crowning).
Preterm and postterm
preterm (labor begins before fetus is mature). and poster (labor is delayed until fetus and placenta have both passed beyond the optimal point for birth
position is important because it can influence both
process and efficiency of labor
the role of prostaglandins answers the often asked question..."does coitus help induce labor?" semen contains...which can help with what?
prostaglandins, which can be helpful in softening, aka "ripening" of the cervix. If a cervix is ready to ripen, semen prostaglandins could possible stimulate the beginning of contractions.
on occasion, especially after administration of a narcotic to the mother, a... may appear
pseudosinusoidal or false sinusoidal pattern.
temp obtained how often
q 4 hrs during labor Report a temperature greater than 99°F (37.2°C) because it may indicate the development of infection. Unless there are accompanying symptoms, however, temperature elevation in a woman who has taken little fluid by mouth usually reflects dehydration (urge her to drink at least sips of water to maintain hydration). After rupture of the membranes, temperature should be taken every 2 hours because the possibility for infection markedly increases after that time.
after estimatingg intensity or duration of contraction...
recheck the fundus at the conclusion of the contraction to be certain it does relax and becomes soft to the touch again. This demonstrates that the uterus is not in continuous contraction but is providing a relaxation time, during which placental blood vessels can fill to supply the fetus with adequate oxygen.
If a support person is hesitant to give coaching instructions
review techniques rather than take over
as fetal head is pushed out of birth canal, it extends and then...
rotates to bring the shoulders into the best line with the pelvis. The body of the baby is then born.
In a breech position, what is the chosen point?
sacrum (Sa)
in.a shoulder presentation, what is the chosen point?
scapula or acromion process (A)
length of contractions
simply observe the rhythm strip and, using the time line, count the number of seconds the contraction lasted. To determine the beginning of a contraction without a monitor, rest a hand on a woman's abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction (Fig. 15.13). Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. It is possible to palpate this tensing approximately 5 seconds before the woman is able to feel the contraction because contractions become palpable when the intrauterine pressure reaches approximately 20 mmHg. However, the pain of a contraction is not usually felt until pressure reaches approximately 25 mmHg.
Why observe if there is a period of relaxation between contractions?
so the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus.
if partner wants to hold infant
sterile blanket?
assessments of cervical dilation are subjective or objective?
subjective
pain is...
subjective. also assess how much discomfort she is experiencing and how he feels about her labor not just by a pain scale but by subtle signs like facial expressions, flushing or paleness, hands in a fist, rapid breathing, etc.
Smallest anteroposterior diameter
suboccipitobregmatic measurement (9.5 cm) and is measure from inferior aspect of occiput to center of anterior fontanelle
1/4 labors begin with spontaneouss rupture of fetal membranes, when this occurs a woman feels a ...
sudden gush or slow trickle of amniotic fluid
Respiratory system: The process of labor appears to aid in the maturation of
surfactant production by alveoli in the fetal lung. Both the pressure applied to the chest from contractions and passage through the birth canal help to clear the respiratory tract of lung fluid. For this reason, an infant born vaginally is usually able to establish respirations more easily than a fetus born by cesarean birth.
if a disproportion between fetus and pelvis occurs, what structure is at fault?
the pelvis. if the fetus is the cause of the disproportion, it is often not because the head is too large but because it is presenting to the birth canal at less than its narrowest diameter. keep this in mind when discussing w parents why an infant may not be able to be born vaginally. it can be upsetting to learn a child cant be born vaginally bc of a mothers pelvis being too small but it can be more upsetting to think the baby head is too big (they end up thinking something is wrong with the baby) avoiding negative thoughts like this promote good child/health bonding
Fetal Lie
the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a woman's body-in other words whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position. About 96% of fetuses assume a longitudinal lie (with their long axis parallel to the long axis of the woman)
station
the relationship of the presenting part of the fetus to the level of the ischial spines
fetal position
the relationship of the presenting part to a specific quadrant and side of a woman's pelvis.
engagement, what does descent mean as well?
the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. Descent to this point means the widest part of the fetus (the presenting skull diameter in a cephalic presentation, or the intertrochanteric diameter in a breech presentation) has passed through the pelvis or the pelvic inlet has been proven adequate for birth. descent is the widest part of the fetus is able to fit through
be sure to ascertain fetal heart sounds at the beginning of the second stage to ensure...
the start of the baby's passage into the birth canal is not occluding the cord and interfering with fetal circulation.
third stage lasts from
time infant is born until after delivery of placenta
second stage lasts from
time of full dilation until infant is born
if an infant is smaller than usual. an attempt to turn the fetus to...
to a horizontal lie (external fetal version) may be made. a preterm baby's skull is not nearly as mature as a full term baby, so coming out longitudinal would fuse bones.
