Labor and Birth

Question 1

Process of Labor - 4Ps

Answer 1

• Labor: coordinated sequence of involuntary, intermittent uterine contractions.
• Birth: the actual event.
• Four major factors (4Ps) interact during normal childbirth:
  = Powers (uterine contractions, includes effacement and dilation)
  = Passageway (mother’s rigid bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and introitus)
  = Passenger (fetus, membranes, and placenta)
  = Psyche (woman’s emotional structure)

Question 2

Attitude

Answer 2

• is the relationship of the fetal body parts to one another.
• Normal intrauterine attitude is flexion (fetal back is rounded, head is forward on the chest, and arms and legs are folded in against the body.

Question 3

Lie

Answer 3

• Relationship of the spine of the fetus to the spine of the mother.
• Longitudinal or vertical: fetal spine is parallel to the mother’s
• Transverse or horizontal: fetal spine is at a right angle, or perpendicular, to the mother’s spine.

Question 4

Presentation

Answer 4

• Portion of fetus that enters the pelvic inlet first.
• Cephalic: head first (has 4 variations - vertex, military, brow, and face).
• Breech: buttocks present first (has 3 variations - frank, full or complete, and footling).
• Shoulder: fetus is in a transverse lie, or the arm, back abdomen, or side could present.

Question 5

Position

Answer 5

Relationship of assigned area of the presenting part or landmark to the maternal pelvis.
- vertex, face, breech, brow and shoulder presentations.

Question 6

Station

Answer 6

• the measurement of the progress of descent in cm above or below the midplane from the presenting part to the ischial spine.
• Station 0: at ischial spine.
• Minus station: above ischial spine.
• Plus station: below ischial spine.
• Engagement: when the widest diameter of the presenting part has passed the inlet; corresponds to a ) station.

Question 7

Mechanisms of Labor: Assessment

Answer 7

• Lightening or dropping: also known as engagement and occurs when the fetus descends in the pelvis about two weeks before birth (most noticeable in first pregnancies).
• Braxton Hicks contractions increase.
• Vaginal mucosa is congested, and discharge increases.
• Brownish or blood-tinged cervical mucus is passed.
• cervix ripens, becomes soft and partly effaced, and may begin to dilate.
• mother has a sudden burst of energy (nesting), often 24 to 48h before onset of labor.
• weight loss of 1-3lb results from fluid shifts produced by changes in progesterone and estrogen levels 24-48h before the onset of labor.
• spontaneous rupture of membranes occurs.

Question 8

Mechanism of Labor: process

Answer 8

• Engagement: fetus nestles in the pelvis, occurs when presenting part reaches the level of the ischial spines.
• Descent: process that the fetal head undergoes through the pelvis. Continuous process from prior to engagement until birth and is assessed by station.
• Flexion: process of nodding of the fetal head forward toward the chest.
• Internal rotation: assumed at engagement into the pelvis while descending.
• Extension: enables the head to emerge when the fetus is in cephalic position. Begins after the head crowns and is complete when the head passes under the symphysis pubis and occiput.
• Restitution: realignment of the fetal head with the body after the head emerges.
• External rotation: shoulder externally rotate after the head emerges and restitution occurs.
• Expulsion: birth of the entire body.

Question 9

Leopold’s Maneuvers

Answer 9

• methods of palpation to determine presentation and position of the fetus and aid in location of fetal of fetal heart sounds.
• buttocks feel soft and have an irregular shape.
• fetus’s back is a smooth, hard surface.
• Irregular knobs and lumps, may be the hands, feet, and knees (felt on the opposite side of the abdomen).

Question 10

Breathing Techniques

Answer 10

• Provide a focus during contractions, interfering with pain sensory transmission.
• promote relaxation and oxygenation.
• divided in first-stage breathing and second-stage.

Question 11

Fetal Monitoring

Answer 11

• displays the fetal heart rate
• monitors uterine activity
• assesses frequency, duration, and intensity of contractions
• assesses FHR in relation to maternal contractions
• FHR baseline is measured between contractions
• normal at term is 110 to 160 bpm (FHR)

Question 12

External Fetal Monitoring

Answer 12

• noninvasive
• performed with a tocotransducer or doppler ultrasonic transducer
• ultrasound transducer is placed over the location of the fetal’s back.
• the tocotransducer is placed over the fundus of the uterus.
• position client at comfortable position, avoiding vena cava compression.

Question 13

Internal Fetal Monitoring

Answer 13

• invasive and requires rupturing of the membranes and attaching an electrode to the presenting part of the fetus.
• client must be dilated 2-3 cm.

Question 14

Fetal bradycardia or tachycardia

Answer 14

< 110 or > 160 bpm for more than 10 min.

- if either occurs, change the mother’s position, adm oxygen, and assess mother’s VS. Notify PHCP ASAP.

Question 15

Variability in Fetal Heart Rate

Answer 15

• Fluctuations in baseline FHR
• absent or undetected is considered nonreassuring
• decreased can result in from fetal hypoxemia, acidosis, or certain medications.
• a temporary decrease can occur when fetus is sleeping (do not usually lasts longer than 30 min).
  = absent: undetected variability.
  = minimal: not more than 5 bpm.
  = moderate: fluctuations are 6 to 25 bpm.
  = marked: fluctuations are greater than 25 bpm

Question 16

Accelerations in FHR

Answer 16

• brief, temporary increases of at least 15 bpm and lasting at least 15 seconds.
• usually are a reassuring sign, reflecting a responsive, nonacidotic fetus.
• usually occurs with fetal movement
• may be nonperiodic (no relation to contraction) or periodic (with contractions).
• may occur with uterine contractions, vaginal examinations, or mild cord compression, or when the fetus is in a breech presentation.

Question 17

Early decelerations

Answer 17

• decreases in FHR (usually remains greater than 100)
• occur during contractions as the fetal head is pressed against the mother’s pelvis or soft tissues, and return to baseline by the end of contraction.
• tracing shows a uniform shape and mirror image of uterine contractions.
• early decelerations are not associated with fetal compromise and require no intervention.

Question 18

Late decelerations

Answer 18

• are nonreassuring patterns that reflect impaired placental exchange or uteroplacental insufficiency.
• begins well after the contraction and return to baseline after the contraction ends.
• interventions include immediately improving placental blood flow and fetal oxygenation.

Question 19

Variable decelerations

Answer 19

• caused by conditions that restrict flow through the umbilical cord.
• shape, duration and degree are variable; these fall and rise abruptly with the onset and relief of cord compression.
• also may be nonperiodic, occurring at times unrelated to contractions.
• if occurs, discontinue oxytocin if infusing, change the position of mother, adm oxygen, assess mother’s VS, and notify PHCP.
• assist with amnioinfusion (intrauterine instillation of warmed saline to decrease compression on the umbilical cord) if prescribed.

Question 20

Hypertonic uterine activity

Answer 20

• assessment includes frequency, duration, intensity of contractions, and resting tone.
• performed either by palpating by hand or with an internal uterine pressure catheter (IUPC).
• uterus should relax between contractions for 60 seconds or longer.
• uterine contraction intensity is about 50 to 75 mmHg (with IUPC) during labor and may reach 110 mmHg with pushing during the second stage.
• average resting tone is 5 to 15 mmHg.
• in hypertonic uterine activity, the resting tone between contractions is high, reducing blood flow and decreasing fetal oxygen supply.

Question 21

Nonreassuring FHR patterns

Answer 21

• bradycardia
• tachycardia
• late decelerations
• prolonged decelerations
• hypertonic uterine activity
• decreased or absent variability
• variable decelerations falling to less than 70 bpm for longer than 60 seconds.

Question 22

Priority Nursing Actions for Nonreassuring FHR patterns

Answer 22

• identify the cause
• discontinue oxytocin infusion
• change the mother’s position
• adm oxygen by face mask at 8-10L/min and infuse IV fluids as prescribed
• prepare to initiate continuous electronic fetal monitoring with internal devices if not contraindicated
• prepare for cesarean delivery if necessary
• document the event, actions taken, and the mother’s response.

Question 23

Four Stages of Labor: Stage 1 (Latent phase)

Answer 23

• the longest
• cervical dilation is 1 to 4 cm
• contractions occur every 15 to 30 min, are 15 to 30 seconds, and mild intensity.
• assist with comfort measures, keep mother and partner informed, offer fluids and ice chips, encourage voiding every 1 to 2 hours.

Question 24

Four Stages of Labor: Stage 1 (Active phase)

Answer 24

• dilation is 4 to 7 cm
• contractions occur every 3 to 5 min, are 30 to 60 seconds, and moderate intensity
• encourage effective breathing, provide quite environment, keep mother and partner informed, promote comfort with back rubs, sacral pressure, pillow support, and position changes. Instruct partner in effleurage (light stroking of abdomen). Offer fluids and ice chips, encourage voiding every 1 to 2 hours.

Question 25

Four Stages of Labor: Stage 1 (Transition phase)

Answer 25

• dilation is 8 to 10 cm
• contractions occur every 2 to 3 min, are 45 to 90 seconds, and strong intensity.
• encourage rest between contractions, begin breathing pattern, keep mother and partner informed, provide privacy, offer fluid and ice chips and ointment for dry lips. Encourage voiding every 1 to 2 hours.
• if the membranes have ruptured, assess the FHR because of the rick of prolapsed umbilical cord, and assess the color of the amniotic fluid, because meconium-stained fluid can indicate fetal distress.

Question 26

Four Stages of Labor: Stage 2

Answer 26

• dilation is complete
• progress of labor is measured by descent of fetal head through the birth canal
• contractions occur every 2 to 3 min, are 60 to 75 seconds, and strong intensity.
• increase in bloody show occurs.
• mother feels urge to push (ferguson reflex)
• perform assessment every 5 min, monitor maternal VS, monitor FHR before, during, and after contractions, monitor uterine contractions, provide mother with encouragement and praise and rest between contractions, keep both informed, maintain privacy, provide ice chips and ointment for lips, prepare for birth.

Question 27

Four Stages of Labor: Stage 3

Answer 27

• contractions occur until the placenta is expelled
• placenta separation and expulsion occur (usually 5 to 30 min after birth)
• assess maternal VS, uterine status.
• after expulsion of placenta, fundus remains firm and is located 2 fingers bellow the umbilicus.
• examine placenta for cotyledons and membranes to verify that is intact
• promote parental-neonatal attachment

Question 28

Four Stages of Labor: Stage 4

Answer 28

• period 1 to 4 hours after birth
• BP returns to prelabor level
• pulse is slightly lower
• fundus remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus.
• perform maternal assessment every 15 min for 1h, every 30 min for 1h, and hourly for 2h.
• provide warm blankets, apply ice to the perineum, massage the uterus if needed and teach the mother.
• provide breast-feeding support as needed.

Question 29

Anesthesia: Local

Answer 29

• used for blocking pain during episiotomy
• adm just before the birth
• has no effect on the fetus

Question 30

Anesthesia: Lumber epidural block

Answer 30

• injection is in L3 to L4 space
• adm after labor is established or as partial anesthesia just before a scheduled c-section.
• relieves pain from contractions and numbs the vagina and perineum.
• may cause hypotension, bladder distension, and a prolonged second stage
• assess maternal BP and bladder frequently
• maintain the mother at side lying position or place a rolled blanket beneath the right hip.
• observe for any adverse effects (nausea, vomiting, pruritis or respiratory depression).

Question 31

Anesthesia: Intrathecal opioid analgesics

Answer 31

• injected into the subarachnoid space and has a rapid onset of action.
• may be used in combination with a lumber epidural block.

Question 32

Anesthesia: Subarachnoid (spinal) block

Answer 32

• injection site is in the spinal subarachnoid space at L3 to L5.
• block is adm just before birth
• relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities.
• may cause maternal hypotension and postpartum headache
• mother must lie flat for 8 to 12 hours after spinal injection.

Question 33

Anesthesia: General

Answer 33

• may be used for some surgical interventions
• mother is not awake
• presents a maternal danger of respiratory depression, vomiting, and aspiration.

Question 34

Bishop Score

Answer 34

• used to determine maternal readiness for labor and evaluates cervical status and fetal position.
• indicated before the induction of labor
• the 5 factors are assigned a score of 0 to 3. and the total score is calculated.
• a score of 8 or greater indicates that the chance of successful vaginal delivery is good and the cervix is favorable for induction.
• the 5 factors: dilation, effacement, consistency, and position of cervix, station of presenting part.

Question 35

Obstetrical Procedures: Induction

Answer 35

• a deliberate initiation of uterine contractions that stimulates labor.
• elective induction may be accomplished by oxytocin infusion.
• increase the IV dosage of oxytocin as prescribed only after assessing contractions, FHR, and maternal BP and pulse.
• do not increase the rate when the desired contraction pattern is obtained (2-3 min and lasting 60 sec).
• oxytocin infusion is discontinued if uterine contraction frequency is less than 2 min or duration is longer than 90 seconds, or if fetal distress is noted.

Question 36

Obstetrical Procedures: Amniotomy

Answer 36

• artificial rupture of the membranes is performed to stimulate labor.
• performed of the fetus is at 0 or a plus station.
• increases the risk of prolapsed cord and infection.
• monitor FHR before and after, record time of procedure and characteristics of the fluid.
• meconium-stained may be associated with fetal distress and bloody may indicate abruptio placentae or fetal trauma.
• unpleasant odor may be infection
• polyhydramnios is associated with maternal diabetes and certain congenital disorders.
• oligohydramnios is associated with intrauterine growth restriction and congenital disorders.
• expect more variable decelerations after rupture.

Question 37

Obstetrical Procedures: External version

Answer 37

• manipulation of the fetus from an unfavorable presentation into a favorable presentation for birth.
• indicated for abnormal presentation after the 34th week.
• US is used during procedure
• abdominal wall is manipulated to direct the fetus into a cephalic position.
• after the procedure: perform a nonstress test, monitor for uterine activity, bleeding, ruptured membranes, and decreased fetal activity. With Rh- perform Kleihauer-betke test as prescribed to detect the presence and amount of fetal blood in the maternal circulation and to identify clients who need additional Rh immune globulin.

Question 38

Obstetrical Procedures: Episiotomy

Answer 38

• an incision made into the perineum to enlarge the vaginal outlet and facilitate birth.
• the use of this procedure has declined over the years.
• institute measures to relieve pain.
• provide ice packs during the first 24h
• apply analgesic spray or ointment as prescribed
• provide perineal care and instruct client to proper care.
• report any bleeding or discharge to PHCP

Question 39

Obstetrical Procedures: Forceps delivery

Answer 39

• two double-crossed spoon-like articulated blades are used to assist in the delivery of the fetal head.
• check the neonate and mother after delivery for any possible injury.
• assist with repair of any lacerations

Question 40

Obstetrical Procedures: Vacuum extraction

Answer 40

• a cap-like suction device is applied to the fetal head to facilitate extraction.
• traction is applied during contractions until descent of the head is achieved.
• should not be kept in place for more than 25 minutes.
• monitor FHR frequently and assess infant at birth and throughout the postpartum period for signs of cerebral trauma.
• monitor for developing cephalhematoma.
• caput succedaneum is normal and resolves in 24h.

Question 41

Obstetrical Procedures: Cesarean delivery

Answer 41

• usually through a transabdominal, low-segment incision of the uterus.
• need informed consent.
• ensure that the preoperative tests are done (including Rh).
• insert IV and urinary catheter
• prepare abdomen as prescribed
• postoperative: encourage turning, coughing, deep breathing, ambulation, bonding and attachment. Monitor for sign of infection, bleeding and thrombophlebitis.

Question 42

True and false labor

Answer 42

• True: contractions may manifest as back pain and often resemble menstrual pain. There is an increase in duration and intensity and cervical dilation and effacement are progressive, with engagement and descent of the fetus.
• False: known as prodromal labor, are felt in the abdomen and groin and may be more annoying than painful. Contractions are irregular and do not produce dilation, effacement, or descent. Walking usually helps.