Chapter 16
Leopold maneuvers
Abdominal palpation that identifies the number of fetuses, presenting part, fetal lie, and fetal attitude
Postanesthesia recovery (PAR) score (What are the components of this score?)
Activity, respirations, blood pressure, level of consciousness, and color
Leopold maneuvers
Also identifies degree of descent into the pelvis of the presenting part; and expected location of the point of maximal intensity (PMI) of the FHR on the woman's abdomen.
Ambulation
Ambulation is associated with improved uterine contraction intensity and shorter labors, less need for pain medications, reduced rate of operative birth, increased maternal autonomy and control, distraction from the discomforts of labor and an opportunity for close interaction with the woman's partner.
Bearing-down efforts
An involuntary response to the Ferguson reflex
True labor versus false labor
During the third trimester of pregnancy women should be instructed regarding the stages of labor and the signs indicating its onset. They should be informed of the possibility that they will not be admitted if they are 3 cm or less dilated.
Duration
Each contraction exhibits a wavelike pattern. It begins with a slow increment (the "building up" of a contraction from its onset), gradually reaches a peak, and diminishes rapidly (decrement, the "letting down" of the contraction). An interval of rest ends when the next contraction begins.
Intensity
Each contraction exhibits a wavelike pattern. It begins with a slow increment (the "building up" of a contraction from its onset), gradually reaches a peak, and diminishes rapidly (decrement, the "letting down" of the contraction). An interval of rest ends when the next contraction begins.
Frequency
Each contraction exhibits a wavelike pattern. It begins with a slow increment (the "building up" of a contraction from its onset), gradually reaches a peak, and diminishes rapidly (decrement, the "letting down" of the contraction). An interval of rest ends when the next contraction begins. The "frequency" refers to how often uterine contractions occur.
Resting tone
Each contraction exhibits a wavelike pattern. It begins with a slow increment (the "building up" of a contraction from its onset), gradually reaches a peak, and diminishes rapidly (decrement, the "letting down" of the contraction). An interval of rest ends when the next contraction begins. The "resting tone" refers to the relaxation of the uterus.
Assessment of uterine contractions
Several methods are used to evaluate uterine contractions, including the woman's subjective description, palpation and timing of contractions by a health care provider, and electronic monitoring.
Fern test
Spread drop of fluid from vagina on a slide and examine under microscope. Observe for appearance of ferning (a frondlike crystalline pattern) or absence of ferning (alerts staff to possibility that amount of specimen was inadequate or that specimen was urine, vaginal discharge or blood).
Fern test
Test for rupture of membranes using vaginal fluid
Latent phase (second stage of labor)
The latent phase is a period of rest and relative calm (i.e., "laboring down"). During this early phase the fetus continues to descend passively through the birth canal and rotate to an anterior position as a result of ongoing uterine contractions. The woman is quiet and often relaxes with her eyes closed between contractions. The urge to bear down is not strong, and some women do not experience it at all or only during the acme (peak) of a contraction.
Latent phase (first stage of labor)
The latent phase is the first phase of first stage of labor.
Psychosocial factors
The woman's general appearance and behavior (and that of her partner) provide valuable clues to the type of supportive care she will need.
Box 16-6
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Latent phase (first stage of labor)
0-3 cm of dilation
Active phase (first stage of labor)
4 to 7 cm of dilation
Transition phase (first stage of labor)
8 to 10 cm of dilation
Postanesthesia recovery (PAR) score
A PAR score is determined for each woman on arrival to the obstetric recovery area and is updated as part of every 15-minute assessment.
EMTALA
A federal regulation enacted to ensure that a woman gets emergency treatment or active labor care whenever such treatment is sought. According to the EMTALA, true labor is considered to be an emergency medical condition.
Perineal trauma related to childbirth
Acute injuries of the perineum, vagina, and uterus during childbirth
Latent phase (second stage of labor)
A period of rest and relative calm
Doula
A specially trained, experienced female labor attendant
Amniotomy
Artifical rupture of membranes
Psychosocial factors
Assess woman and partner for verbal interactions, body language, perceptual ability, and discomfort level
Second stage of labor
Begins with full cervical dilation (10 cm) and complete effacement (100%)
Active pushing phase (second stage of labor)
Characterized by strong urges to bear down
First stage of labor
Consists of 3 phases marked by cervical dilation
True labor versus false labor (What should the nurse compare when assessing this?)
Contractions, cervix, engagement of fetus in pelvis
Schultze or Duncan mechanism
Describes the appearance of the placenta
Birth plan
Describes the woman's available options, wishes, and preferences
Voiding (Why is this important?)
Distended bladder may impede descent of the presenting part
Active pushing phase (second stage of labor)
During the phase of active pushing (descent) the woman has strong urges to bear down as the Ferguson reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor. At this point the fetal station is usually +1, and the position is anterior. This stimulation causes the release of oxytocin from the posterior pituitary gland, which provokes stronger expulsive uterine contractions.
EMTALA
Emergency Medical Treatment and Active Labor Act
Voiding
Encourage voiding every 2 hours. A distended bladder may impede descent of the presenting part, slow or stop uterine contractions, and lead to decreased bladder tone or uterine atony after birth. Women who receive epidural analgesia or anesthesia are especially at risk for the retention of urine. Therefore the need to void should be assessed more frequently with them.
Assessment of uterine contractions (What characteristics are used for this?)
Frequency, intensity, duration, and resting tone
Episiotomy
If an episiotomy is necessary, it is done when the perineal musculature is distended to minimize soft-tissue damage. A local anesthetic may be administered if necessary before performing an episiotomy. An episiotomy can be midline or mediolateral.
Episiotomy
Incision into the perineum to enlarge the vaginal outlet
Prenatal data
Includes woman's age, general health status, current medical conditions or allergies, obstetric history
Chorioamnionitis
Infection of fetal membranes after ROM
Ambulation (When can this be encouraged?)
Intact membrane, presenting part engaged after ROM, no pain medication administered to woman
Third stage of labor
Lasts from birth of the baby until the placenta is expelled
PMI of FHR
Location on maternal abdomen where FHR is heard the loudest
Perineal trauma related to childbirth
Most acute injuries and lacerations of the perineum, vagina, uterus, and their support tissues occur during childbirth. Some degree of damage occurs to the soft tissues of the birth canal and adjacent structures during every birth.
Common maternal position during labor and birth
Much research continues to focus on acquiring a better understanding of the physiologic and psychologic effects of maternal position in labor. Other common positions include lateral, upright, and hands-and-knees.
Nuchal cord
Occurs when the umbilical cord becomes wrapped around the fetal neck
Crowning
Occurs when the widest part of the head distends the vulva just before birth
Vaginal exam
Perform a vaginal examination on admission, before administering medications (e.g., analgesics, increasing oxytocin infusion), when significant change has occurred in uterine activity, on maternal perception of perineal pressure or the urge to bear down, when membranes rupture, or when you note variable decelerations of the FHR.
Amniotomy
Performed by the physician or certified nurse-midwife using a plastic AmniHook or a surgical clamp.
Perineal lacerations
Perineal lacerations usually occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth: first, second, third, and fourth degree.
Third stage of labor
The goals in the management of the third stage of labor are the prompt separation and expulsion of the placenta achieved in the easiest, safest manner. The third stage is generally by far the shortest stage of labor. The placenta is almost always expelled within 15 minutes after the birth of the baby.
Bearing-down efforts
Reflexively, the woman begins to exert downward pressure by contracting her abdominal muscles while relaxing her pelvic floor.
Vaginal exam
Reveals whether the woman is in true labor
Common maternal position during labor and birth
Semirecumbant
Nitrazine (pH) test
Test for rupture of membranes using dye
PMI of FHR
The PMI is usually directly over the fetal back, and is located based on fetal presentation. In a vertex presentation you can usually hear the FHR below the mother'sumbilicus in either the right or the left lower quadrant of the abdomen. In a breech presentation you usually hear the FHR above the mother's umbilicus.
Active phase (first stage of labor)
The active phase is the second phase of first stage of labor.
Birth plan
The birth plan should include preferences related to: Presence of birth companions or others, clothing to be worn, environmental modifications, labor activities, comfort and relaxation measures, medical interventions, care and handling of the newborn immediately after birth, and cultural and religious requirements.
Fourth stage of labor
The first 1 to 2 hours after birth
First stage of labor
The first stage of labor begins with the onset of regular uterine contractions and ends with complete cervical effacement and dilation. Includes latent, active, and transition phases.
Fourth stage of labor
The fourth stage of labor is a crucial time for mother and newborn. Both are not only recovering from the physical process of birth but are also becoming acquainted with one another and additional family members. During this time maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize.
Assessment
The nurse first performs a screening assessment by using the techniques of interview and physical assessment and reviews the laboratory and diagnostic test findings to determine the health status of the woman and her fetus and the progress of her labor.
Schultze or Duncan mechanism
The placenta first appears by its shiny fetal surface (Schultze mechanism) or its dark roughened maternal surface first (Duncan mechanism). There is no clinical significance to which side first appears.
Prenatal data
The prenatal data is used to identify the woman's needs and risks. The nurse should review the woman's prenatal records carefully, taking note of her obstetric and pregnancy history, including gravidity; parity; and problems such as history of vaginal bleeding, gestational hypertension, anemia, pregestational or gestational diabetes, infections (e.g., bacterial, viral, sexually transmitted), and immunodeficiency status. In addition, the expected date of birth (EDB) should be confirmed. Other important data found in the prenatal record include patterns of maternal weight gain; physiologic measurements such as maternal vital signs (blood pressure, temperature, pulse, respirations); fundal height; baseline fetal heart rate (FHR); and laboratory and diagnostic test results.
Doula
The primary role of the doula is to focus on the laboring woman and provide physical and emotional support by using soft, reassuring words of praise and encouragement touching; stroking; and hugging.
Second stage of labor
The second stage of labor is the stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. It is composed of two phases: the latent phase and the active pushing (descent) phase.
Intensity
The strength of a contraction at its peak
Resting tone
The tension in the uterine muscle between contractions
Duration
The time that elapses between the onset and end of a contraction
Frequency
The time that elapses from the beginning of one contraction to the beginning of the next
Transition phase (first stage of labor)
The transition phase is the third phase of first stage of labor.
Nuchal cord
The umbilical cord often encircles the neck, but rarely so tightly as to cause hypoxia. After the head is born, gentle palpation is used to feel for the cord. If present, the health care provider slips it gently over the head if possible. If the loop is tight or if there is a second loop, he or she usually clamps the cord twice, cuts between the clamps, and unwinds the cord from around the neck before the birth is allowed to continue.
Assessment
Top priority for the woman presenting with signs of labor
Perineal lacerations
Trauma to the perineum during childbirth
Nitrazine (pH) test
Using Nitrazine dye for determining pH differentiates amniotic fluid, which is slightly alkaline, from urine and purulent material [pus], which are acidic.
Chorioamnionitis
When membranes rupture, microorganisms from the vagina can then ascend into the amniotic sac, causing chorioamnionitis and placentitis to develop.
Crowning
With voluntary bearing-down efforts the head appears at the introitus. Crowning occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth. Immediately before birth the perineal musculature becomes greatly distended.
