OB Exam #3

Intrapartal Period: From the beginning of contractions through

delivery of the newborn and placenta and the first 1-4 hours.
Intrapartal Care: Medical and nursing care given to pregnant
woman and family during labor and birth.

Length of Labor
o Primigravida
Average: 12-18 hours
I in 100 women < 3 hours
1 in 9 women > 24 hours
o Multipara
Average: 8-10 hours
7 in 100 women < 3 hours
1 in 33 women > 24 hours

Factors Affecting Labor:
o 1.) Passageway
The pelvis & birth canal
Factors affecting the passage:
Musculoskeletal deformities
Uterine neoplasms ( fibroids)
Bicornuate uterus (2 horns)
Maternal dwarfism
Nutritional deficiencies/diseases
Pelvic trauma















o 2.) Passenger
Passenger: Fetal head size and position
Refers to the ability of the fetus to move through the
passage.
This is based upon:
Biparietal diameter
o Is usually the most important measurement
o This is the distance between the parietal
bosses
o The head can mold-change shape to fit
through the pelvis
o The size of the fetal head and capability of
the head to mold to the passageway
o The head is the largest part
of term infant


Passenger: Fetopelvic relationships
o Fetal lie
Relationship of the long axis of the fetus
to long axis of the mother
Longitudinal (up and down with
mother)
Oblique (diagonally)
Transverse (fetus horizontal)


o Fetal Presentations
Part of fetus that enters maternal pelvis
3 types:
o 1. Cephalic
o 2. Breech
3%
Presentations:
o Frank Breech
Station

Transverse lie

Increased fetal
mortality/morbidity
Associated with:
o Prematurity
o Placenta previa
o Multiparity
o Some
congenital
anomalies








Fetal Attitude
o Relationship of fetal parts to one another (degree or
extension of fetal head in cephalic presentations)
o Flexion is what we want (vertex)


Fetal Positions
o Relationship of a particular reference point of the
presenting part of the fetus to the maternal pelvis










Occiput anterior (OA)= results in easiest vaginal birth

Occiput posterior (OP)= may slow descent







o Passenger: Placenta



























o 3.) Power
Frequency: Beginning of one contraction to the beginning
of the next
Duration: Start to end of one contraction
Intensity: Strength of the contraction
Once woman is 10 cm/fully dilated, she starts pushing


o 4.) Psyche
Psychological state, support system, preparation for
childbirth, past experiences, coping strategies
Fear/safety
Control
Medicalization of childbirth
Pain and perception of pain
o 5.) Position
Squatting position opens diameter about 20%











True Labor vs. False Labor

True Labor
Contractions:
o Regular intervals
o Start in back and sweep to abdomen
o Increase in intensity/duration
o Intensified by walking
Bloody show:
o Usually present
Effect of sedation:
o Does not stop contractions
Cervical effacement and dilation

False Labor
o Contractions:
o Irregular intervals
o Mostly in abdomen
o Intensity is same or variable, and dont become more
frequent
o Walking has no intensifying effect
o NO bloody show
o Effect of Sedation
o Tends to decrease # of contractions
o No cervical change

Labor Onset
o Theories of labor initiation
o Maternal factor theories
1. Uterine size
once gets to certain size initiates prostaglandins
2. Pressure on cervix
3. Progesterone withdrawal
in animals decreased progesterone leads to labor
4. Oxytocin stimulation


o Fetal factor theories
1. Placental aging
ages after 41 weeks after pregnancy
2. Fetal endocrine control
3. Prostaglandin synthesis

Signs/Symptoms of Impeding Labor


o Lightening/engagement
o Lightening-Descent of fetus into the pelvis
o Engagement- Widest diameter of presenting
part
Has passed the inlet (0 station)
o Baby drops; lightening occurs














o Presenting part: Engaged
Signs and symptoms of
the baby engaging:
Urinary frequency, backache, leg pain,
dependent edema, and easier respirations
o Presenting part: Dipping
o Presenting part: Floating
o Braxton Hicks contractions
o Irregular, intermittent contractions
o May be felt in groin, fundus
o Loss of mucus plug
Presenting part:Floating

Presenting part: Dipping

Presenting part: Engaged

o Thick mucus which has sealed the endocervical canal during
pregnancy
o Prevents ascent of bacteria or other substances
o Expelled when cervical dilatation begins
o May indicate labor within a few days
o Cervical changes
o Cervix is opening
o Softening, ripening
o Cervical dilatation/effacement
o Position change

o
o






















Cervical Changes




o Rupture of membranes
o Diagnosis
Pooling Nitrazine paper
Nitrazine paper turns blue
Amniotic fluid (Alkaline)
Urine (Acidic)
SSE - ferning
o Teaching
Nothing in vagina
Notify HCP
Hand washing
Temp q2 hours
Change pads often
o Nursing actions when SROM occurs
o Check FHR
The very first thing to check should be the fetal heart
rate; bc of pressure cord may all of a sudden push
down (prolapsed cord) always rule out
o Other symptoms of labor
o Burst of energy or fatigue/tension
o Weight loss
1-3 lbs a couple days before labor; dont know what
causes this
o Diarrhea, not feeling well

History of Childbirth in America

o Evidence based Practice?
o Evidence-based obstetric care is a relatively new concept,
which had its origins in the early 1970s when Iain Chalmers
and his colleagues in Oxford responded to the statement of
Archie Cochrane that much of the evidence underpinning
obstetric (and other) practices was flawed. (J. King, 2005)












First Stage of Labor

o Definition: onset of contractions to complete dilatation (0-10cm)
o Physiologic changes
o Cardiovascular
Increased cardiac output, little HR/BP change
o GI
Slowing of gastric emptying
Motility
Absorption
N/V
o Renal
Full bladder
Increased pain, slows labor & fetal descent
Proteinuria
o Respiratory
Exhales more CO2
o Latent Phase
o Definition: onset of regular contractions- 3-4 cm
o Length:
Primigravidas: 8-20 hours
Multiparas: 5-14 hours
o Contractions

Irregular, Q 10-20 mins, 15-45 second duration
Increase in frequency, duration, intensity to q 3-5
minutes, 60 sec long
o Emotional Responses
Anxiety, relief, excitement
o Active Phase
o Definition: 3-4 cm- 7-8cm
o Contractions
Q 3-5 min, 45-60 seconds, moderate intensity
o Emotional response
Serious, turns inward
Decreased energy
Fatigue
o Transition Phase
o Definition: 7-8 cm--- 10cm
o Contractions
Q 2-3 min, 60-90 seconds duration, strong intensity
o Signs/Symptoms
Nausea, vomiting, trembling limbs, increased bloody
show, urge to push, pelvic pressure, irritability
o Emotional Response
Discouragement, irritability, panicky, impatient, feels
out of control
Nursing Care for Normal Labor

o Assessment
o maternal and fetal status, labor status
o Diagnosis
o Active labor, reassuring FHR, tolerating labor, need for
hydration, nutrition, ambulation, monitoring, consultation
o Plan
o Ambulation, hydration, FHR, privacy, pain medication
o Implementation
o Evaluation

Assessment

1. Maternal VS
q 30-60 min, T q 4 hours; if ROM, q 2 hours

2. Urine dipstick

3. Assess fetal lie and fundal height

4. Determine fetal position, # of fetuses, approximates fetal size




Leopolds maneuvers




5. Assessment: Uterine Contractions
o Onset; Frequency, Duration, Intensity
a.) Palpation
Figure out Indentability of uterus
o Mild-
feels like end of nose




easily identifiable
o Moderate-
feels like chin; some indentation
o Strong/firm-
feels like forehead,, cannot be
indented
b.) Tonus (electronic fetal monitoring)- Tells when
but not how strong they are
External (toco transducer)- Measures
pressure inside the uterus
Internal (intrauterine pressure catheter)
o (ICPC)
o 30-50 mm Hg needed
o Risks: infection, uterine rupture
6. Assessment: Vaginal Exam
o Cervical effacement and dilatation
o Station
o Presenting part
o Position- suture and feel for soft spot
o Status of membranes- did it rupture? Feels like balloon
o (cervical exam may need to be done every 2 hours; some
women may hate this bc the cervix may be tipped
backwards)
7. Assessment: Vaginal Discharge
o Bloody show
Amount
Characteristics
Mucus-y rather than really bloody
o Evaluate amniotic fluid
Type of rupture (SROM, AROM)
Color (clear) If brown or stool in it than risk factor
Amount
Odor
8. Assessment: Fetal status
o Auscultation of fetal heart rate (FHR)
Doppler or Doptone
Normal range 120-160
Check q 15-30 minutes in active labor
Decelerations
Changes in variability
Rate
o Intermittent fetal heart rate auscultation allows:
Freedom of movement
Upright positions
Patient satisfaction
Natural progression of labor
























Location of FHR















o External Fetal Monitoring

o Internal Fetal Monitoring
o Insertion of Fetal scalp electrode (FSE)


Factors indicating use of electronic fetal monitoring
o Abnormal contraction stress test/decreased fetal movement
o Multiple gestation
o Placenta previa or abruption
o Oxytocin infusion
o Fetal bradycardia/tachycardia
o Maternal complications
o Postdates or preterm
o Meconium stained fluid




FHR Changes
o Baseline FHR
o Normal: 110-160
o Need >10 minutes to establish a baseline (which is between
contractions
o Bradycardia
o Definition <110bpm
o Need to differentiate from maternal HR
o First thing: hands/knees position, reposition mother
o Causes:
Decreased cord perfusion
Meds
Decompensated fetus
Anomalies
Placental separation















o Tachycardia
o Definition: >160 bpm
o Fetal distress if it lasts or accompanied by late decelerations
o No variability. Mother gets sick then fetus follows.
o Causes:
Maternal fever/infection
Meds
Prolonged fetal activity

FHR CHANGES: FHR ACCELERATIONS




FHR CHANGES: FHR DECELERATIONS





EARLY DECELERATIONS


Head getting compressed, pretty common











LATE DECELERATIONS

Does not start to go down until middle and does not recovery
by the end. Should recover by the end of the contraction.
Thought to be due to uteral placenta deficiencies. Flatter the
line the more concerning.




VARIABLE DECELERATIONS

Think of Ws or Vs. Goes down quick and comes back quick.
Usually from cord compression. Will try to turn the mother and
intervene.




V-E-A-L-C-H-O-P
FHR descriptors -- Due to:
Variable decelerations Cord compression
Early decelerations Head compression
Accelerations Ok
Late decelerations Placenta insufficiency







Prolonged Deceleration

o Visually apparent FHR decrease below baseline
o 15 bpm or more
o Lasting 2 min or more
o Less than 10 min from onset to return to baseline
o Not good

FHR CHANGES: Baseline Variability

o Baseline variability
o Fluctuations in the FHR of 2 cycles/min or greater
o Looking for lots of fluctuations
Absent- amplitude range undetectable
Minimal- amplitude range detectable but < 5bpm
Moderate- (normal)-amplitude range of 6-25 bpm
Marked- amplitude range >25 bpm





















FHR VARIABILITY
Moderate FHR Variability FHR Variability: Absent






















Background- Continuous electronic fetal monitoring

o Started in 1960s
o Goal- to diagnose fetal academia, prevent fetal morbidity and
mortality
o Routine in most US hospitals
o Given that available data do not clearly support EFM over IA,
either option is acceptable in a pt without complications.
American College of OB-GYN (ACOG)

Evidence based Practice: Electronic Fetal Monitoring vs Intermittent
Auscultation

o Cochrane analysis (12 RCTs, n >37,000)-comparing EFM to
intermittent auscultation (IA) found that EFM:
o Increased C/S
o Increased use of vacuum and forceps
o No difference in perinatal mortality
o No difference in cerebral palsy
o No difference in Apgars <7 at 5 minutes


9. Assessment: Hydration Status
o Intake and output
o Voiding q 2 hours
o Uterus works better and dilates better
o Oral nutrition in labor is safe and optimizes outcomes
o Routine hospital admission orders include IV, NPO/ice
chips only
o Rationales for this practice include:
Prevention of aspiration in event of general
anesthesia
Importance of hydration can be managed via IV
fluids
o Evidence based practice:
IV fluids do not improve birth outcomes
Fasting in labor increases gastric acid production
Risk of aspiration during general anesthesia has
significantly decreased
o Oral hydration-Practical Application
o Baby weight related to amount of fluid woman receives
during labor
o Food and clear fluids for low risk women:
Provide hydration and nutrition
Give comfort
o IV fluids reserved for women who are:
At high risk for complications
Require continuous IV access
Unable to maintain adequate oral intake
In preterm labor to diminish contractions
o Saline lock- Intermittent IV access
Group B Strep prophylaxis

10. Assessment: Comfort Measures
o Increase use of non-pharmacologic methods of pain relief
o Ambulation and freedom of movement
o Hydrotherapy during the active phase of labor
o Continuous labor support

11. Position Changes
o Ambulation and freedom
of movement in labor is
safe, enhances patient
satisfaction, and
facilitates the progress of
labor
o Lying supine
decreases blood
flow
Blood flow to
the fetus is
reduced
when women
lie on their
backs due to
compression
of the vena
cava by the
gravid uterus












o Squatting or kneeling increases pelvic diameters
MRI data has demonstrated an increase in anterior-
posterior and transverse diameters of the pelvis in
pregnant women who are squatting or kneeling as
compared with lying supine
Squatting or kneeling may help fetus through pelvis in
second stage
o Cochrane analysis
(21 RCTs, n=3706)upright positions in first stage
associated with:
Shorter labors
Less reported pain, fewer epidurals
No adverse effects
A Cochrane analysis of 21 randomly controlled trials
included 3706 women and found that upright positions
in the first stage of labor were associated with shorter
labors, less reported pain and fewer epidurals. There
were no adverse effects for this practice.

o Evidence Based Practice:
o Hands and knees position during first stage of labor
o Increases fetal rotation from OP to OA
o Reduces persistent back pain


11. Assess labor progress/contraction pattern/pain
o Continuous labor support should be the standard of care for all
laboring women
o Historically, partners and support persons banned from hospital
delivery suites to maintain asepsis
o Alternative childbirth movement of 1970s brought fathers into
delivery rooms
o Klaus and Kennell study (1986) renewed interest in support
persons for laboring women
o Evidence Based Practice:
o Continuous Labor Support
Cochrane review (16 RCTs, n >13,000)- continuous
labor support:
Increased:
o Spontaneous vaginal birth
o Shorter labor
o Satisfaction
Less use of pain meds



12. Keep support people informed of progress
o Support persons include midwives, doulas, one-one nursing care,
partners, families, and friends
o Supportive care in labor:
o Emotional support
o Comfort measures
o Information
o Advocacy

Pain Management

o Causes of intrapartal pain:
o Uterine contractions
o Uterine stretching
o Dilating and effacing of the cervical os
o Fetal presentation





























Pain in Labor
o Physiologic responses:
o Increased BP, P, R, perspiration
o Increased pupil diameter, muscle tension
o Nonverbal
o Withdrawal
o Hostility
o Depression
o Verbal
o Pain
o Moaning
o Groaning

Interventions for Pain in Labor
o Depends on:
o Gestation
o Frequency, duration, intensity of contractions
o Labor progress
o Maternal response to pain and labor
Allergies/sensitivities

Factors Affecting Pain Perception
o Previous experience, personal expectations
o Cultural concept of pain
o Rapidly progressive labor
o Fear, anxiety, and fatigue


Nursing Goals for Pain Management
o Provide maximal pain relief with maximal safety for mother and
infant
o Collaborate with woman and birth attendant to determine most
effective pain relief method

Non-Pharmacologic Pain Management
o Relaxation Techniques
o Controlled breathing (Lamaze, Bradley)
o Why Helpful?
o Hyperventilating
o Mouth and hand get tingly
o To cure hyperventilation: brownbag no smells. Help change
breathing to keep going
o Visual imagery/hypnosis; use of focal point
o Movement, position changes, ambulation
o Hydrotherapy
o Background: Hydrotherapy has not been routinely used in
labor due to the concern that it would increase the risk for
maternal and or fetal infection
o Evidence Based Practice: Hydrotherapy is safe and effective in
decreasing pain during active labor
Cochrane analysis (8 RCTs, n=2939):
Hydrotherapy during active labor decreases:
o Use of anesthesia
o Reported Pain
No adverse maternal or neonatal outcomes
Touch
o Acupressure/acupuncture
o Skin stimulation (Gate Control Theory of
Pain)
o Massage/counter pressure
o Application of hot or cold
o Other non pharmacologic methods
o Music
o Aromatherapy-lavender
o TENS (transcutaneous electrical nerve stimulation)
o Sterile water papules

Pharmacologic Methods of Pain Management

Drugs
o Narcotic analgesics
o Morphine, Demerol, Nubain, Numorphan, Stadol, Fentanyl
o Morphine- not given because its long acting
Maternal effects
N/V, mild respiratory depression, transient
mental impairment
Fetal effects
Neonatal Respiratory Depression*
Reverse with opiate antagonist
(Naloxone/Narcan)
Nursing actions
Monitor VS, FHR
Safety precautions
Avoid administration within 1-4 hours of
delivery and with no signs of fetal distress




o Barbiturates
o Infrequent use
o Will keep in hospital, long acting drug
o Early or prodromal labor
o Relieve anxiety/promote sleep
Secobarbital (Seconal)
Pentobarbital (Nembutal)
Diazepam (Valium) *not recommended
o Tranquilizers
o Infrequent use
o Reduce anxiety
o Potentiate narcotics
Hydroxyzine (Vistaril/Atarax)
Only given PO or IM bc it really burns. Never give SQ!!
o Intrathecal
o Narcotic injected into subarachnoid space
o Side effects:
Pruritus, N/V, Urinary Retention


















































Epidural
Anesthesia
o Maternal effects
o Hypotension
-FETAL DISTRESS
fetal side effect of epidural in labor is fetal distress due
to maternal hypotension. Usually around 5cm mark.
Give bolus of IV fluids before epidural to stop
hypotension.
o Allergic/toxic reaction
o Accidental spinal puncture-headache!
o Respiratory paralysis
o Partial or total anesthetic failure
o Difficulty pushing
o Difficulty voiding
Cath may be put in to help voiding. Dont let be on
back for too long.
o Effects on labor/delivery process
? Increase length of labor, increase operative delivery
o Push caffeinen to get rid of HA postpartum
o Goes to lungs because of positioning
o Switch women onto different sides every hour

























o Fetal effects
o Fetal distress R/T maternal hypotension
o ? effect on lactation/sucking ability


Epidural Anesthesia: Nursing Actions
o Monitor VS often
o Q 5 minutes during administration
o Monitor sensation/ability to move legs
o Emergency equipment available
o Suction/O2
o Medications
o 1:1 nursing care


Second Stage of Labor

o Definition: Begins with complete cervical dilatation-ends with the
birth of infant
o Signs/Symptoms
o Increased show, increased urge to push, FHT lower in pelvis
o Phases of Second Stage
o Short latent phase
o Active phase
o Contractions
o Q 2-3 min, 50-90 seconds, strong intensity
o Length
o Nullipara: 1-2 hours
o Multipara: 20 minutes
o Emotional Response
o Focused, increased energy, tired, happy to participate,
burning, splitting apart
o Positions
o Change is good every 20 to 30 minutes while pushing
o Pushing techniques
o Valsalva (closed glottis) pushing
Will most likely see with-hold breath and push as long
as possible 3x per contraction
o Spontaneous (open glottis) pushing
Non epidural will push when feels urge





o Background:
o Second stage without epidural:
Spontaneous urge to push after a short latent period
Spontaneous bearing down reflex with vertex descends
to or near pelvic floor
o Second stage with epidural
Suppressed bearing down reflex- higher levels of
vacuum and forcep use
Higher rate of instrumental birth
Longer second stage

Evidence Based Practice:
o Spontaneous vs Closed Glottis Pushing
o Sustained Valsalva bearing down efforts:
o Increases:
FHR decelerations
Maternal fatigue
Perineal tears
Urinary stress incontinence postpartum
o Decreases:
Umbilical cord pH values




Evidence Based Practice:
o Pushing with Epidurals
o 7 RCTS of initial period of passive descent (laboring down)
vs. immediate pushing in primigravidas with epidurals found
that passive descent
Increased incidence of spontaneous birth
Reduced risk of instrument-assisted delivery
Decreased active pushing time
No change in cesarean section rate

Practical Application:
o Honor the lull phase: time between complete dilation and the
onset of spontaneous bearing down efforts
o Support and encouragement of the natural bearing down process
o With epidural: laboring down




Cardinal Movements
















1. Descent
2. Flexion
3. Internal rotation
4. Extension
5. Restitution
6. External rotation
7. Expulsion

A,B= descent
C= internal rotation
D= extension
E= external rotation














1. DESCENT






















2. FLEXION





















3. INTERNAL ROTATION



4. EXTENSION


EXTENSION CONTINUES: CROWNING























5. RESTITUTION

6. EXTERNAL ROTATION





















7. EXPULSION























Nursing Care During Birth

o Assess maternal status (VS, fatigue, coping)
o Assess fetal status (FHR q 5-15 min)
o Environment (calm, quiet for relaxation)
o Encouragement/information (mirror, touch)
o Positioning (upright positions)
o Intake/output
o Perineal care













Episiotomy
o There is no evidence to support routine episiotomy or aggressive
perineal massage at birth




Background
o Routine episiotomy
o One of the most common OB procedures
o 60% of births in 1979
o 24.5% in 2004
o Initial rationale:
Shorten second stage
Reduce risk of perineal trauma and subsequent pelvic
floor dysfunction
o The management of the perineum during second stage is
individualized and provider specific.
o Providers include doctors and midwives range from doing
nothing to supporting the perineum to aggressive massage
and episiotomy
o The focus should be to prevent tearing and genital tract
trauma and increase the womans satisfaction and comfort.
o According to some studies, when performed judiciously, the
episiotomy could be below 15% of all vaginal births in the US.
o Benchmark episiotomy rates of 2% or less have been
reported in large studies of American women with
physiologic care.
o Research reports that theres no need for a routine
episiotomy. There can, however, be some very specific
circumstance when it may be indicated. These indications
might be the following:
Extensive vaginal tearing appears likely, abnormal fetal
position or the baby needs to be delivered quickly
o Indications
o Prolonged low FHR, resistant perineum
o Complications
o Pain, infection, hematoma
o Types of Episiotomy
o Median and Mediolaternal



















MIDLINE EPISIOTOMY















Evidence Based
Practice: Episiotomy
o Episiotomy is associated with increased:
o Third and fourth degree lacerations
o Pain
o Healing complications

Evidence Based Practice: Perineal Massage
o Antenatal perineal massage
o Decreases lacerations requiring suturing in primiparous
women
o Reduces need for episiotomy
o Decreases perineal pain postpartum
o Perineal massage at birth
o No difference in perineal trauma

Birth Maneuvers: Practical Application
o Avoid episiotomy
o Support antenatal perineal massage
o Hands off the perineum at birth

Delayed cord clamping improves neonatal outcomes
o Background:
o Immediate cord clamping is routine in most institutions
o The timing of cord clamping affects amount of blood the
newborn receives
o What is the optimum timing for the neonate?
o Evidence Based Practice:
o Meta-analysis (15 RCTs and non-RCTs, n=1912) compared
late cord clamping (delayed at least two minutes) to
immediate cord clamping
o Late cord clamping:
Improved newborn hematocrit
Reduced risk of newborn anemia
Benefits extend several months into infancy
Increased benign polycythemia
o Practical Application
o Delay clamping of the cord for a few minutes or until the
cord stops pulsating. Keep infant at level of maternal heart.

Immediate skin-to-skin contact after birth
o Promotes thermoregulation, improves initial breastfeeding, and
facilitates early maternal-infant bonding
o Background:
o Routine hospital practice after delivery:
Newborn handed to mother for a moment of
immediately taken to separate table for evaluation and
observation
Newborn returned to parents warm, dry, and wrapped
in blankets
o Evidence Based Practice:
o 30 studies (n-1925) found:
Immediate mother and infant skin-to-skin contact:
Keeps the newborn warmer
Reduces infant crying in the first house of life
Improves breastfeeding initiation and duration
Improves infant sleeping and maternal
attachment behavior
o Practical Application:
o Honor the golden hour
Place healthy newborn directly onto mothers chest
Assess vital signs while newborn on mothers chest
Delay routine newborn evaluation
Encourage breastfeeding within the first hour of life

Operative Delivery-Forceps









Forceps Delivery
o Types
o Low forceps preferred
o Nursing Actions
o Empty bladder; lithotomy position
o Monitor FHR
o Monitor contractions
o Potential Complications
o Maternal
Vaginal or cervical lacerations
Urinary retention postpartum
o Fetal
Infant bruising/abrasions at site of forcep application
Brachial palsy
Subdural hematoma
Rare: skull fracture/intracranial hemorrhage

o Indications for use:
o Prolonged 2
nd
stage,
maternal exhaustion,
fetal distress, fetal
malpresentations,
cardiac
decompensation
o From 1997-2008: The use
of forceps to aid delivery
declined by 32 percent,
from 14 percent to 10
percent

Vacuum Extractor





Anesthesia for Delivery
1. Pudendal
Provides light anesthesia on peri
neum; used just prior to delivery,
anesthetizes pudendal nerves, done
intravaginally; TAKES AWAY BEARING DOWN
SENSATION





Indications for use:
o Prolonged second stage
o maternal exhaustion
o fetal distress
o fetal malpresentations
o cardiac decompensation
Nursing Actions
o Lithotomy position
o Monitor FHR
Potential Complications
o Maternal
Perineal, vaginal, cervical
lacerations
o Infant
Trauma at site (scalp
laceration
Cephalohematoma
Rarely, subgaleal
hemorrhage
Cerebral irritation (poor
suck-swallow, irritability
Jaundice

2. Local








3. Paracervical 4. Spinal
o Rare
o Fetal bradycardia


5. General
o Used primarily for emergency C/S
o High risk of fetal respiratory depression
o Risk of maternal aspiration
o Systemic
o Used mostly for emergency cesarean deliveries or complications of
delivery
o Risks:
o High risk of fetal respiratory depression
o Most general anesthetics reach the fetus in about two
minutes
o So, not usually used with high risk fetuses, such as preterm
infants if possible
o Most general anesthetics may also cause vomiting and
aspiration


Nursing Care for Women Receiving Anesthesia

Perineum is injected
with lidocaine
Used primarily for c-
sections
Lasts up to 6 hrs
Usually requires woman to
lie flat for several hours to
avoid HA
During the process of rapid induction of anesthesia, the nurse
applies cricoid pressure to occlude the esophagus and prevent
possible aspiration; the esophagus is occluded by depressing
the cricoid cartilage 2-3 cm posteriorly and maintained until
the anesthesiologist has placed the endotracheal tube
1. Assist with Positioning

2. Assess Pain/Effectiveness of Treatment
3. Assess VS & FHR
Trying to rule out maternal hypotension, respiratory
depression
4. Assess Intake/Output
5. Assess sensation level/ability to move legs
6. Ongoing positioning
Watch positioning; no prolonged pressure on anesthetized
part-pillow between legs
Third Stage of Labor
o Definition: Begins with birth of infant; ends with delivery of
placenta
o Usually 5-30 minutes; because of decreased uterine surface area-
placenta separates
o 2 Phases
o Placental separation
o Placental expulsion


Types of Placental Delivery
o Spontaneous
o Schultz mechanism
o Duncan mechanism
o Manual extraction

Evidence Based Care: Active Management of 3
rd
Stage Labor
1. Administration of oxytocic agent prior to placental delivery
2. Early clamping and cutting of the umbilical cord
3. Application of controlled traction to the cord
Results in -
o Reduced maternal blood loss
o Reduced cases of postpartum hemorrhage
o Lower incidence of prolonged 3
rd
stage of labor
o Disadvantages: increased n/v, elevated BP with certain medications,
pain

Third Stage of Labor: Emotional Responses
o Joy, relief, fatigue, eager to share news
o Grief work
o Loss of pregnancy as valued object
o Loss of valued status as pregnant woman
o Possible sense of failure
Not achieving own expectation for labor and birth
o Loss of some aspects of self (altered body image, self
esteem, changed self concept, loss of former role)
o Nursing Actions
o Early infant contact ASAP on mothers abdomen if not
contraindicated
o Encourage touching/hold of infant
o Keep baby skin to skin with warm blankets over both of them
o Initiate breast feeding soon after birth (good for mom and
baby)
o Monitor fundal height of uterus/bleeding
Monitor firmness of uterus and vaginal bleeding EBL
<500cc
o Ice pack to perineum/episiotomy x 12-24 hrs

Fourth Stage of Labor
o Definition:
o Physiologic adjustment during 1
st
1-4 hours
o Period of maternal transition, involves physiologic
adjustment of womans body during first 1-4 hours
o Uterus usually contracts in midline of abdomen midway
between the umbilicus and symphysis pubis
o Nursing Care:
o VS q 15 minutes
Low BP is often late sign of blood loss
Temp often slightly elevated (dehydration, fatigue)
o Monitor uterine involution
Check/massage as necessary fundus q 15 min: for
position, size, firmness
o Monitor lochia q 15 min x4, then q 30 min x2, then hourly
x2; (vaginal bleeding/discharge) r/o pph; medication to
control the bleeding prn
(Monitor bleeding)
o Perineal inspection
Edges approximated, clean, no hematomas
o Monitor urine output; encourage bladder emptying
o Comfort measures
Blankets, hydration, pain meds, ice to perineum
Calm quit enviornment














FUNDAL PALPATION
Suggested method of palpating the fundus of the uterus
during the 4
th
stage
The left hand is placed just above the symphysis pubis and
gentle downward pressure is exerted
The right hand is cupped around the uterine fundus




















Lie
= The relationship between the long axis of the fetus and the long
axis of the mother
o Longitudinal line- fetus is lengthwise or vertical
o Transverse lie- fetus is horizontal

Presenting Part
= The part of the fetus that lies closest to the internal os of the
cervix

Station
= The relationship of the presenting part of the fetus to the
imaginary line between the ischial spines of the pelvis
One Station- The presenting part of the fetus is 1 cm past the
imaginary line (0 station) between the ischial spines

The Order of Cardinal Movements of Labor and Birth
1. Descent
2. Flexion
3. Internal Rotation
4. Extension
5. Restitution
6. External Rotation and Expulsion

LOA
Left occiput anterior
o Fetal occiptal lobe is facing anteriorly and left of the maternal
pelvis